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ABORTION

SPONTANEOUS AND INDUCED
MEDICAL AND SOCIAL ASPECTS

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ABORTION

SPONTANEOUS AND INDUCED

MEDICAL AND SOCIAL ASPECTS

FREDERICK J. TAUSSIG, M.D, F.A.C.S.

PROFESSOR OF CLINICAL OBSTETRICS AND CLINICAL GYNECOLOGY, WASHINGTON
UNIVERSITY SCHOOL OF MEDICINE, ST. LOUIS

ILLUSTRATED

THIS VOLUME IS ONE OF A SERIES
DEALING WITH MEDICAL ASPECTS
OF HUMAN FERTILITY SPONSORED BY

THE NATIONAL COMMITTEE ON MATERNAL HEALTH, INC.

LONDON

HENRY KIMPTON

263 High Holborn, W. C.
1936

Printed in U. S. A.

rWBlCO^.ElijSTITUTE 1

1 LIBRARY

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The C. V. Mosby Company
St. Louis

PREFACE

Abortion lias become a world problem. From both a medical and a
social viewpoint, largely as a result of the World War, this question is
engaging the serious attention of every physician interested in the
preservation of maternal health. Through the inspiration of Dr. R. L.
Dickinson, chairman of the executive committee of the National Com¬
mittee on Maternal Health, and with the assistance of members of that
committee and its staff of workers, I have been enabled to complete the
present volume from t his broader viewpoint. Social aspects have been
included in this volume intended for physicians because in preventive
medicine underlying social conditions should always be taken into con-
sideration.

While my debt is greatest to Dr. R. L. Dickinson and the members
of his committee, thanks are also due to Professor Walter Gellhorn, of
Columbia University Law School, for assistance in preparing the chap¬
ter on medicolegal aspects and to Dr. 0. LI. Schwarz for the use of ma¬
terial in the chapter on pathology.

An important contribution is the chapter on Abortion in Animals
written by Professor W. L. Williams, of Cornell University. Based on
a lifetime of personal observations, his review of this subject is au¬
thoritative. I was indeed fortunate to secure his cooperation.

F. J. T.

St. Louis.

FOREWORD

The scourges that science can conquer grow in number. Smallpox
or typhoid or tuberculosis can be cut off whenever we care to pay the
price. This should be true of abortion.

The scourges of the race are fought with success only by forcing
them out of the zone of mystery and sentiment into the zone of fact.
Of old, illness derived from evil spirits, madness from the gods. Within
this ancient circle of emotional unreason and religious taboo we still
strive to keep two master scourges, abortion and venereal disease, and
thus threaten science and sense in all attempts to vanquish them. In
both these matters the public pays dearly in long illness and high death
rate for intimidating its doctors and silencing its social workers.

Therefore we welcome a volume which goes far to move into the zone
of fact a universal human practice, a spreading scourge, a remediable
evil. It is the first book covering the ground with any completeness.
It speaks with authority.

For his task, Dr. Taussig is especially qualified by wide reading and
extensive practical experience not alone in disorders of women and mid¬
wifery but also in the social implications of medicine. He wrote the
first special monograph on abortion in the year 1910, and at that rela¬
tively early date — five years before any attempt to open a clinic —
stressed the possibilities and value of control of conception in limiting
undesirable pregnancies, mentioning some of the measures available at
that time.

The author has devoted no small portion of His life to public health
matters. He was active in the first organization of a national associa¬
tion for social hygiene in St. Louis, about 1909; he originally proposed
an agency for control of cancer in 1904, and again in 1914; and has
rendered to the birth control movement most important aid by counsel
and encouragement.

In the White House Conference his part was the study of abortion
in relation to fetal and maternal mortality. Gathering together all
available data upon this subject, he analyzed the factors that have led

FOREWORD

to the growing frequency of instrumental interruption of pregnancy
with its resulting high puerperal mortality. The startling facts that
were revealed in this survey have been the basis of extensive comment on
the part of many lay journals and have served to awaken the conscience
of the American public to the necessity of taking measures to combat
this evil.

If the scourges that science conquers grow in number, the domain
which surgery conquers widens in area. Among a multitude of surgical
advances, one of the forward movements has been in the field of inter¬
ruption of pregnancy, since in this quarter genuine aseptic procedure
coupled with technical expertness yields a very high degree of safety.
The natural sequel has been swift expansion of operative abortion to
replace useless drugs and bungling methods, but at the same time with
a woeful incidence of unclean, unskillful interference leading to alarm¬
ing mortalities and multitudinous cripplings. The era of fewer and
better abortions therefore awaits, among other issues, a sensible re¬
search in which interruption of pregnancy is treated as if it were con¬
cerned as much with the health of and consideration for the woman
as it is with theological doctrine, as if, in its surgical aspects, it had
to do with surgery.

A field survey is overdue. In all other kinds of surgery except this
one, the medical profession avoids making sweeping criticisms or draw¬
ing conclusions without visits by surgeons of standing to the operating
rooms of those with the most extensive experience, here and abroad —
combining inspection with follow-up, with analysis, with publication of
results, and a differentiation between skilled craftsmen and unclean
and reckless and commercially minded individuals. No survey of op¬
erative abortion is known to have been undertaken, except in Russia
where there are ample facilities but certain handicaps.

This is one of the reasons to welcome the author 's assembly of all
available and basic material and his assessment of method. Tins under¬
taking is preparation for the time when medicine will take on its share
of one more inevitable responsibility, social as well as medical. In this
particular matter law has a lag some decades behind public opinion,
but law can hardly fail eventually to become humane, if only to permit
medicine to become merciful. From the legal angle, quite as much as
from the practical angle, one thing is too evident to need much empha-

FOREWORD

sis. This is that the pivotal point in diminution of abortion is removal
of statutory embargo on diffusion of knowledge of effective control of
conception.

First and last this volume renders service that is fundamental. Learn¬
ing the facts is the first step toward combating any evil, and by facing
facts we may be forced effectively to develop what appears to be the
only cure for this evil and its near relatives; namely, to foster sane sex
life stayed on sound character and built in turn on fearless inquiry and
wise education.

Robert L. Dickinson.

CONTENTS

CHAPTER I

Definition and Scope _________________

Outline of Contents, 22; Scope of Problem, 23; Purpose of This Book, 28.

CHAPTER II

Historical and Racial Aspects _____________

Ethnological Aspects, 38; Spontaneous Abortion, 38; Induced Abortion,
41.

CHAPTER III

Abortion in Animals _________________

The Basic Causes of Abortion, 48; The Immediate or Exciting Causes of
Abortion, 56; The Control of Abortion in Domestic Animals, 65; Abortion
in Captive Wild Animals, 67.

CHAPTER IV

Anatomy and Physiology of Early Pregnancy _________

The Decidual Stage, 70; The Attachment Stage, 7S; Placental Stage, 80;
Physiology, 81.

CHAPTER V

Pathology of Abortion ________________

Uncomplicated Abortion, 83; Retained or Incomplete Abortion, 84.

CHAPTER VI

Etiology of Spontaneous Abortion _____________

Classification, 94; Fundamental Causes, 94; Ovulogenic, 94; Maternal
Causes, 100; Secondary or Exciting Causes, 114.

CHAPTER VII

Prevention of Abortion

Prophylaxis Before Conception, 117; Prophylaxis During Pregnancy, 119;
To Prevent Uterine Contractions, 124.

CHAPTER VIII

Mechanism of Abortion

One-Stage Abortion, 127 ; Two-Stage Abortion, 127 ; Cervical Abortion,
131; Abortion Through Cervico- Vaginal Fistula, 133; Vaginal Abortion,

134.

PAGE

117

127

CONTENTS

CHAPTER IX

PAGE

Symptoms and Signs of Abortion _____________ 135

CHAPTER X

Diagnosis and Differential Diagnosis ___________ 139

Diagnosis of the Abortion, 142; Diagnosis of the Stage of Abortion, 143;
Diagnosis of Petal Death, 146 ; Diagnosis of the Cause of Abortion, 148 ;
Differential Diagnosis, 149.

CHAPTER XI

Treatment of Abortion ________________156

Historical, 156; Differentiation of Clean and Infected Cases, 158; Synop¬
sis of Clinical Experience, 163; Statistical Fallacies, 169; Treatment of
Uninfected and Afebrile Abortion, 170; Treatment of Septic or Febrile
Abortion, 175; Summary of Treatment of Septic Abortion, 182.

CHAPTER XII

Operative Technique _ ________________ 185

Anesthesia, 186; Technique of Dilatation, 188; Technique of Emptying
the Uterus, 190; Technique in Complications, 201.

CHAPTER XIII

Extrauterine Septic Infection ______________ 203

Cellulitis, 203; Peritonitis, 208; Thrombophlebitis and Bacteriemia
(Pyemia), 213.

CHAPTER XIY

Perforation - 223

Summary, 238.

CHAPTER XV

Other Complications of Abortion _____________ 239

Prolonged Retention of Parts, 239; Fatal Hemorrhage, 239; Gangrene
of the Extremities, 242; Abortion in Double or Septate Uterus, 242;
Inversion of the Uterus With Abortion, 244.

CHAPTER XYI

Missed Abortion _ _________________ 245

Etiology, 247; Frequency, 248; Pathology, 249; Symptoms and Clinical
Course, 255; Diagnosis, 257; Complications, 258; Treatment, 259.

CHAPTER XVII

Molar Pregnancy __________________ 260

Blood Mole, 261; Hematoma Mole, 262; Hydatidiform Mole, 267.

CHAPTER XVIII

Sequelae of Abortion _____________ ___ 272

CONTENTS

CHAPTER XIX

PAGE

Indications for Therapeutic Abortion

General Indications, 278; Group Indications, 282; A. Dead Fetus, 283;

B. Living Fetus, 283; (1) Diseases of the Ovum, 283; (2) Pregnancy
Toxemias, 285; (3) Complications of Labor, 288; (4) Diseases of the
Genital Tract, 289; (5) Systemic Diseases, 292; (6) Endocrine Dis¬
turbances, 307; (7) Diseases of the Nervous System, 311; (8) Diseases
of Special Organs (Eye and Ear), 314; (9) Other Unclassified Diseases,

310; (10) Rape, 317; (11) Eugenic Indications, 317; (12) Social-

Economic Indications, 320.

CHAPTER XX

Methods and Technique of Therapeutic Abortion ________ 322

Non-Surgical Methods, 322; Surgical Procedures for Therapeutic Abor¬
tion, 327 ; Stages of Therapeutic Abortion, 328.

CHAPTER XXI

Preventive Measures — Sterilization ____________ 341

Preventive Measures, 341; Sterilization, 342; Non-Surgical Procedures,

342; Surgical Sterilization, 343; Permanent Sterilization, 344; Reversible
Operations for Temporary Sterilization, 347; Tubal Coagulation, 349;
Causes of Failure, 349 ; Choice of Method, 351.

CHAPTER XXII

Methods and Accidents of Illegal Abortion _________ 352

Abortifacients, 352; Accidents of Illegal Abortion, 358.

CHAPTER XXIII

Statistics of Abortion ________________ 3G1

Relation to Population, 3G1 ; Ratio of Abortions to Confinements, 3G4;
Types of Abortion, 3GG; Age of Mother and Number of Pregnancies,

3G9 ; Relation to Marriage, 372; Relation to Duration of Pregnancy, 374;
Relation to Religion, 375; Relation to Race and to Urban or Rural
Groups, 377; Relation of Abortion to Puerperal Septicemia, 379; Rela¬
tion to Preventability, 384; Additional Data on Abortion Mortality, 38G.

CHAPTER XXIV

Economic and Domestic Aspects of

Induced

A BORTION

— O'

°89

CHAPTER XXV

Theological and Ethical Aspects of Induced Abortion

397

CHAPTER XXVI

Legalized Abortion in the Soviet Union ______

Legislation, 405; Statistics, 409; Mortality and Morbidity, 413; The
Russian Abortarium, 415; Summary, 419.

CONTENTS

CHAPTER XXYII

PAGE

Legal Aspects of Induced Abortion ____________ 421

Abortion Laws in Foreign Countries, 422; The Abortion Law in the
United States, 426; Prosecution of Criminal Abortion, 435; New Legis¬
lation on Abortion, 441; Proposed Abortion Law, 442; Revised Statute
on Abortion, 443.

CHAPTER XXVIII

Control of Abortion _________________ 446

APPENDIX

PAGE

A. Statutes Relating to Abortion _____________ 453

B. Source Tables __________________ 476

C. Glossary of Terms _________________ 480

BIBLIOGRAPHY

Books and Monographs _______________ _ 484

Journals 488

ILLUSTRATIONS

PAGE

FIG.

1. Greek abortion instruments _ __ ___________

2. Urn used for preserving embryos ____________

3. Abortion ovum of three months’ pregnancy _________

4. Hawaiian abortion stick _______________

5. Spermatozoa from genitally sound and diseased bulls ______

6. Spermatozoa from an 18-month-old bull, with hypoplasia of genital organs

7. Fused chorions of ovine triplets ____________

S. Fetal cotyledons from healthy and diseased cows _______

9. Magnified villi __________________

10. Passage of impregnated ovum through the fallopian tube _

11. Common sites of implantation of the ovum _________

12. Three very early pregnant uteri _____________

13. Human embryo of about ten days’ fertilization age ______

14. Diagram of the early development of chorionic villi and placenta _ _ _

15. Human embryo of about five weeks’ fertilization age ______

16. Sectional plan of the gravid uterus at three months _______

17. Ovum in situ of about four weeks’ development ________

IS- A. Two months pregnant uterus in normal position in pelvis _

1S-B. Eight weeks pregnant uterus, showing incomplete obliteration of the
uterine cavity _________________

19. Pregnant uterus of four months’ gestation _________

20. Fetus sanguinolentus ________________

21. Fetus compressus __________________

22. Section through retained placenta ____________

23. Section of abortion products _____________

24. Section of degenerated chorionic villi with infected necrotic decidua _

25. Diagrammatic picture of a placental polyp in the uterus _ _

26. Section of a placental polyp ______________

27. Section of postabortive endometritis ___________

28. Section of acute septic endometritis with pronounced leucocytic infiltration

29. Section of syphilis of the placenta ____________

30. Triplet abortion placenta with partly macerated fetuses of about three

months’ development ______________

31. Twisted umbilical cord producing abortion __________

32. Retroverted pregnant uterus ______________

33. Prevention of abortion by replacing the retroverted gravid uterus

34. Instruments for mercury weight treatment _________

35. Mercury weight pressure treatment for replacing the retroverted gravid

uterus

36. One-stage mechanism of abortion ____________

37. Two-stage mechanism of abortion ____________

38. Eight weeks’ fetus with unruptured amniotic sac ________

39. Fetus and placenta of twelve weeks’ development ________

40. Intact uterine cast of decidua _____________

41
44

79
81

85
S5

86
86

88
88

99
109
120
121

1 90

J-LJLJ

128

129

130

131

ILLUSTRATIONS

FIG. PAGE

41. Cervical abortion _________________ 132

42. Abortion through cervico-vaginal fistula __________ 133

43. Placenta of five months7 gestation pocketed in the horn of the uterus _ 137

44. Friedman hormone test for the diagnosis of early pregnancy _ 140

45. Roentgenogram after pneumoperitoneum of pelvic organs in a patient two

months pregnant __________ ______ 141

46. Female sex hormone reaction ______________ 147

47. Differential diagnosis between membranous dysmenorrhea and abortion _ 150

48. Cross-section of uterus containing necrotic myoma _______ 151

49. Differential diagnosis between early pregnancy, myoma of the uterus, and

adenocarcinoma of the uterine body __________ 153

50. Differential diagnosis between tubal pregnancy and abortion complicated by

adnexal infection ________________ 154

51. Dewees7 wire crotchet ________________ 157

52. Hodge 7s ovum forceps _______________ 157

53-A. Colonies of Streptococcus hemolyticus on blood agar ______ 161

53-B. Colonies of Streptococcus viridans on blood agar _______ 161

54. Gauze drainage treatment of septic abortion _ _ _ _ _ _ _ _ _ 181

55. Improvised kitchen table for emergency treatment at home _____ 186

56. Local anesthesia for abortion treatment __________ 187

57. Dilation of the cervix with laminaria and vaginal gauze pack _ 189

58. Schatz 7 metranoikter and Ivlaar’s ovum forceps with T-shaped cuff _ _ 190

59. Removal of loosened and partly expelled ovisac from cervical canal _ _ 191

60. Budin’s method of expressing pieces of loosened retained placenta from the

uterine cavity _________________ 192

61. TIoening7s method of expressing retained placental remnants from the

uterus ___________________ 193

62. Use of the curette in abortion _____________ 194

63. Large blunt spoon curette suitable for the removal of larger pieces of

placenta __________________ 195

64. Technic of curettement ________________ 19 6

65. Blond’s thimble curette for the palpation and removal of placental tis¬

sue from the uterus _______________ 197

66. Ovum forceps removing loosened placental fragments from the uterus _ 197

67. Use of the sponge forceps to loosen and extract retained placenta _ _ 198

68. The finger as an aid in loosening retained placenta from its attachment

to the uterine wall _______________ 199

69. Two fingers used for removing retained placenta, when cervix is opened

widely ___________________ 201

70. Spread of infection from the uterine cavity _________ 204

71. Extrauterine septic infection following abortion ________ 205

72. Parametrial exudate to the right of the uterus and a pyosalpinx to the left 206

73-76. Steps in the incision and drainage of a pelvic abscess _____ 210

77, 78. Drainage treatment of acute pelvic peritonitis _______ 212

79. Septic thrombophlebitis, showing spread along ovarian and uterine veins 213

80. Cross-section of thrombosed vein _____________ 214

81. Low power section of a thrombosed ovarian vein with abscess formation

following septic abortion ______________ 215

82. High power section of a portion of vein seen in Fig. 81 _____ _ 216

88. Streptococcic infection following abortion __________ 217

ILLUSTRATIONS

FIG. PAGE

84, 85. Excision of thrombosed ovarian vein by transperitoneal abdominal op¬
eration ___________________ 220

S6. Anatomical relations of structures exposed by Martens’ extraperitoneal

operation for pelvic thrombosis ____________ 221

87. Graph of incidence of perforation in abortion cases from 1910 to 1923 in

the city of Hamburg _______________ 225

88. Autopsy findings in perforation of the uterus _________ 227

89. Huge perforation of the uterus produced by ovum forceps _ 228

90. Intestinal injury associated with perforation of the uterus _ _ _ _ 230

91. Diagrammatic sketch showing different methods of perforation with the

curette - 231

92. Hematoma of the broad ligament, following rupture of the cervix due to

forcible dilatation ________________ 235

93. Multiple perforations of the uterus produced by the hand of the operator

94. Uterus containing fetal bones _____________

95. Gangrene of the leg after postabortive thrombosis _______

96. Bicornuate pregnant uterus ______________

97. Inversion of the uterus produced by the faulty use of the ovum forceps

in retained abortion _______________

98. Frontispiece from Lamzweerde’s “ History of Uterine Moles” _ _ _

99. Hemi-section of uterus containing a four months’ fetus and placenta, re¬

moved because of maternal tuberculosis _________

100. Microscopic section of degenerated chorionic villi in missed abortion _

101. Section of hydropic chorionic villi ____________

102. Missed abortion with early fetal death __________

103. Ilydramnios ovum in missed abortion ___________

104. The blighted ovum ________________

105. Hydramnios ovisac, 9 cm. in diameter, with 8 mm. embryo _____

106. Carneous mole in situ in the uterus ___________

107. Carneous mole showing small empty amniotic cavity ______

108. Hematoma mole with polypoid hematomata _________

109. Hematoma mole with broad-based hematomata ________

110. Section of chorion from same case, showing blood in fetal vessels

111. Section through cylindrical embryo, showing partial disintegration

112. Diagram showing the development of a hematoma mole _____

113. Hydatidiform mole in process of expulsion from the uterus _

114. Microscopic section of hydatidiform mole _________

115. Prolapse of the pregnant uterus, following rupture of the vesico-uterine

septum ___________________

116. Multiple myomata of the uterus complicated by pregnancy and requiring

hysterectomy _________________

117. Albuminuric retinitis as an index of severe toxemia in nephritis _

118. Uterus removed after injection of paste used for abortion _____

119. Use of uterine pack to stimulate contractions and cause dilatation of the

cervix ___________________

120. Metal dilators used in induction of abortion _________

121. Voorhees bag used for dilating the cervix _____u____

122. Operative abortion by means of the semi-sharp curette ______

123-126. Vaginal hysterotomy for therapeutic abortion ______ 334,

127-129. Abdominal hysterotomy for abortion _________ 337,

240

241

242

243

246

247

250

251
251

9^9

L-nJ -j

253

256

261

262

263

264

265
265
267

269

270

290

291
315
325

329

330

331

0 90
OdiJ

335

338

ILLUSTRATIONS

FIG. PAGE

130. Madlener operation for tubal sterilization _________ 345

131. Resection of a segment of the tube near the uterus for purposes of ster¬

ilization 346

132. Cornual excision of the interstitial portion of the tube ______ 347

133. Cornual excision method of Taussig ___________ 348

134. Dickinson’s method of electro-coagulation of the tubal cornua _ 350

135. Destructive effect of lead on the fetal epithelium of animals _ _ 354

136. Collection of instruments for illegal abortion sold in Paris _ _ _ _ 356

137. Physometra of the uterus due to gas bacillus infection _____ 358

138. Microscopic section of case of physometra _________ 359

139. Bilateral gangrene of the buttocks associated with gas bacillus infection

following uterine abortion - -- -- ________360

140. Comparative mortality rates following abortion of various types _ 378

141. Role of abortion and septicemia in maternal mortality _ _ _ _ _ 381

142. Fall in abortion deaths in Germany during decade following war _ _ 387

143. Signs hung in the waiting room of a Russian abortarium _____ 408

144. Map of the United States, grouping the states according to the legal

exemptions for induced abortion ___________ 431

145. Traumatic injury of the fetus due to criminal instrumentation _ 436

146. Perforation wound in the cervix, followed by fatal peritonitis _ _ _ _ 437

ABORTION

SPONTANEOUS AND INDUCED
MEDICAL AND SOCIAL ASPECTS

ABORTION

CHAPTER I

DEFINITION AND SCOPE

TN THE DEVELOPMENT of our language, it often happens that a
* word, the meaning of which was at one time clear and well-defined,
takes on during the course of centuries a special connotation that tends
to confuse the expression of our ideas. Such a change has taken place
with the word abortion. In the days when Latin was the universal
language of medicine, abortus , from the verb aboriri, signified some¬
thing that had been detached from its site. Referring to the embryo,
it meant that events had transpired to bring about its premature
expulsion.

In 1547 Boorde, in the Breviarie of Health, wrote : “ abhor si on is when
a woman is delyvered of her chylde before her tynie.” Later, with the
development of obstetrics in France and Germany in the seventeenth
century under the guidance of women midwives, the vernacular forms
began to be used in medical parlance, and we find in France the term,
fausse couche; in Germany, Fehlgeburt ; and in England, miscarriage,
commonly used in the sense of abortion.

For a while the terms “ miscarriage ” and “abortion” were used
interchangeably; then they began to take on differentiated meanings.
At the end of the nineteenth century, many writers limited abortion
to interruptions occurring in the first trimester of pregnancy, and
miscarriage to interruptions occurring in the second trimester. Since
many interruptions in the first three months were artificially induced,
contrary to the law, the word abortion was further corrupted to
designate criminal interference with pregnancy. Among the laity
this unfortunate and restricted usage still exists, but in scientific
medical literature a determined effort is being made to restore its
original meaning to the word abortion. This is doubly important now
that our ethical and legal attitude toward the interruption of preg¬
nancy is undergoing radical modification.

Regardless of the cause, therefore, abortion should be defined as
the “detachment or expulsion of the pre viable ovum.”

The term “previable” cannot be defined absolutely, since with im¬
proved methods of incubation and infant feeding we are able to save

ABORTION

babies at earlier stages of development, but for the present, and per¬
haps for some time to come, the lower limit of viability may be taken
to range between the twenty-sixth and the twenty-eighth week of
fetal life.

In this book we are limiting the discussion to uterine abortion, but
it may properly be applied in cases of ectopic pregnancy to tubal
abortion; and it is not limited to the human race, but can be used to
express similar pathologic processes in animals. In this monograph
therefore I have avoided entirely the use of the word miscarriage and
given to it the title Abortion, with the subtitle Spontaneous and In¬
duced to signify separate consideration of the two main etiologic
groups. The definition of particular terms is discussed in some de¬
tail in Appendix C.

Outline of Contents

It will be noted that I have divided the book into four parts: {One)
History and Background; {Two) Spontaneous Abortion; {Three) In¬
duced Abortion; and {Four) Social Aspects of Abortion.

Part One. — In the history and background of abortion, I have first
briefly reviewed the record of past ages with regard to the accidental
and intentional interruption of pregnancy. Then follows a description
of the ethnologic variations in the practice of abortion, demonstrating
how wide is its spread among savages and civilized peoples of all
corners of the world, regardless of race or religion. The final chapter
in this section, contributed by Dr. Walter Long Williams, Professor
Emeritus of Veterinary Science at Cornell University, deals with abor¬
tion among animals. Here we can see many points of similarity be¬
tween spontaneous abortion in animals and in man, especially in the
matter of cause and prevention.

Part Two.— Under spontaneous abortion are considered most of the
fundamental medical questions involved, such as anatomy of early
pregnancy, etiology, pathology, mechanism, symptoms, diagnosis, pre¬
vention, and the treatment of abortion and its complications. This
section of necessity includes some consideration of induced as well as
spontaneous abortions, since the course, the nature of the pathologic
changes, and the manner of treatment are to a large degree similar
in both forms, regardless of the cause. Perforation and infection, for
example, may result in the handling of either spontaneous or induced
abortion. To avoid duplication, therefore, I have considered all such
matters in this section. For convenience, also, I have treated some of
the less frequent conditions, such as 44 missed abortion” and mole
pregnancy, in separate chapters.

DEFINITION AND SCOPE

Part Three— Under the head of induced abortion will be found
chapters dealing with the medical aspects of legally induced or thera¬
peutic abortion, its indications and technique ; preventive measures
such as contraception and sterilization; and the methods and accidents
of illegally induced abortion. These chapters together with portions
of Part Two will, it is hoped, give to the practitioner of medicine the
necessary information required for the management of abortion.

Part Four. — Social aspects of abortion are reserved for separate
consideration in the concluding section. An initial chapter takes up
in detail the statistical material on abortion, which has been gathered
largely along medico-social lines such as age, multiparity, race, legiti¬
macy, religious affiliations, place of residence and so forth. The social,
economic and religious aspects of induced abortion are then discussed.
This portion of the book should be of interest both to the socially
minded physician and to the medical sociologist. As an outstanding
example of an attempt to solve the abortion problem along socialistic
lines, the Russian experiment in legalization has seemed worthy of
separate consideration. In the concluding chapters on Legal Aspects
and the Control of Abortion I have tried to summarize the methods
of prevention and treatment that give promise of reducing the fre¬
quency of abortion and limitation of the disease and death that fol¬
lows in its wake.

At the end of the volume will be found references to literature (es¬
pecially that subsequent to 1923) ; a few longer statistical tables; the
exact wording and analysis of our State abortion laws ; and a glossary
of terms, with discussion of definitions.

Scope of Problem

Since conditions in other countries, especially those of Western
Europe, are similar to our own, the general scope of the abortion
problem can perhaps be realized by considering the frequency of
abortion, and the number of abortion deaths here in the United States,
so far as these can now be determined.

If there are difficulties in the registration of births in this country
and throughout the civilized world ; if even with the development of
a Federal service of vital statistics in the Census Bureau, we find that
in many states the methods employed have been so inaccurate that
these states could not, until recently, be included in the Birth-registra¬
tion Area, how vastly more difficult does our problem become, when
we seek to arrive at some fair estimate of the number of abortions
and the maternal deaths that result therefrom !

ABORTION

All efforts to make compulsory the registration of abortions have
met with failure. In the very nature of things, it is hardly possible
to expect any other outcome. The desire to avoid any public record
of an event that is so often tied up with the moral life of the individual
is bound to result in failure to get accurate information. Innumerable
are the abortions done by the patient or in the patient’s home, where
no record whatsoever is available for medical inspection. Even where
the patient enters a hospital, we find that the admission record may
specify such a diagnosis as ‘‘uterine bleeding” or “endometritis,”
and a curettement is then done with the connivance of the physician
in charge. Many therapeutic abortions appear in the records as
“dilatation and curettage.”

The same lack of honesty appears in our mortality records, where
we find cases of abortion death registered as pneumonia, kidney dis¬
ease, or heart failure. The recent splendid statistical investigations
of maternal mortality made in New York and Philadelphia show that
in 25 to 30 per cent of abortion deaths a false diagnosis was put upon
the death certificate. These errors were detected only by a meticulous
follow-up of hospital records and personal interviews made by the
physicians in charge of the survey.

If, in spite of all these difficulties, I venture upon an inquiry into
the scope of the abortion problem, it is because there is available
from various sources, information which, when put together will, I
believe, give us a basis for an approximate answer.

This information is directed along three lines:

( A ) The total number of abortions;

(B) The death rate from abortion; and

If we seek information on these three points independently, and if
we find that

A x B = C

then we may feel reassured as to the accuracy of our figures.

(A) dotal Abortions. — Regarding the number of abortions, we find
the most varied guesses made bj^ various obstetricians. In Ger¬
many, for instance, estimates range from 300,000 to 1,000,000 annu¬
ally. In this country, equally extravagant statements have been re¬
corded, such as 100,000 annually in New York City. The number of
abortions treated in hospitals is only a small proportion of the total,
and cannot be used even as an approximate figure.

In 1910, in the first edition of my monograph, then called “The
Prevention and treatment of Abortion” I included a very meager
report based on the histories obtained from 600 gynecological patients

DEFINITION AND SCOPE

regarding their previous conceptions. Following 1,241 conceptions,
they reported 870 full-term confinements, and 371 abortions, or a
ratio of one abortion to 2.3 confinements. The figures obtained simi¬
larly by Macomber in Boston, from the records of 250 married women,
showed 128 abortions to 440 confinements, a ratio of 1 :3.4.

These ratios are, of course, made on too small a basis to have more
than a tentative value, but t li eyr coincide remarkably with the findings
made on the very extensive data reported by Dr. Kopp in her mono¬
graph “Birth Control in Practice.” In a study of 10,000 case histories
in the New York clinic, she found a record of 11,172 abortions as
compared with 27,813 confinements in a total of 38,985 pregnancies.
This makes the ratio of one abortion to 2.5 confinements. The reason

why figures obtained from clinical records are so much more reliable
than those derived by other methods, is the simple psychological fact
that people do not hesitate to tell the truth if they are no longer in
danger of being punished or otherwise exposed to censure for their
actions. Every practitioner has been impressed with the frankness
with which patients will discuss past induced abortions, and with their
subterfuges when an immediate one is under consideration. The truth
can therefore be obtained only through such tabulations of past events.

That the material obtained through maternal health clinics gives a
reasonably accurate picture of conditions in our large cities is hardly
open to question. Whether the same figures apply to the provincial
sections of the country is, however, more than doubtful. All our evi¬
dence, both in this country and abroad, points to a markedly lower
incidence of abortion in rural and small-town practice. I wish there
were available at present more data relating to this subject, but
unfortunately there is only one report, that of Plass, from the rural
districts of Iowa. His figures were obtained from 81 physicians with
country practice who gave their estimate as to the proportion of abor¬
tions to confinements. This indicated a ratio of one abortion to
five confinements in country practice, or about half the city ratio.
Additional information, which I am now trying to collect from various
other districts, cannot be utilized for this volume, but I do not believe
that the results will differ materially.

Our next step is to figure out from the total annual number of births
in this country, a reasonably accurate estimate of the number of abor-
tions. With a population of 120,000,000, and a birth rate of approxi¬
mately 20 per 1,000, we would get 2,400,000 births annually. This
corresponds fairly to the figures now available from the Birth-regis¬
tration Area in the United States. If we now divide these 2,400,000
births into 42 per cent urban, and 58 per cent rural, as indicated by

ABORTION

the Federal Census, and divide these figures by the respective ratios
of one abortion to 2.5 births in urban districts, and one abortion to
five births in rural districts, we get the following1 figures :

Urban: 42 x 2,400,000 = 1,008,000 ~ 2.5 = 403,200 abortions

Rural : 58 x 2,400,000 = 1,392,000 v 5 = 278,400 abortions

This would make a total of 681,600 abortions annually in the United
States.

(B) Death Bate. — The abortion death rate, if we take only figures
obtained from hospital sources, ranges from 2 to 4 per cent depending
upon the country and the type of patient sent to the particular in¬
stitutions reporting. From a collection of figures from a variety and
number of places (not including Russia where legalized abortion is
done under especially favorable conditions with a low mortality rate),
I obtained an average of 2.1 per cent abortion mortality. I must, how¬
ever, consider this figure somewhat too high. In increasing numbers,
women, having learned the risks of abortion, are more careful that
instrumental interference is done with as much asepsis as possible.
The equipment of the average abortionist has also greatly improved,
so that doubtless many abortions are successfully done in office or
home without mortality. A larger proportion of the complicated,
infected cases sooner or later are upon the records of the hospital or
of coroners* inquests. Hence we must assume that the actual mortality
of all types of abortions, simple as well as complicated, is somewhat
less than 2 per cent. Freudenberg, from his very careful review of all
abortion deaths in Germany, arrives at a figure of 1.2 per cent mor¬
tality, and this it would seem to me is probably very near the actual
truth.

( C ) Abortion Deaths. — The number of deaths from abortion is only
in part available from the Census Bureau. The interesting and accu¬
rate study of maternal mortality conducted by the Children's Bureau,
and just issued in its complete form, comprises material in thirteen
states for the year 1927, and for these same states and two others in
1928. There were 1,824 deaths in these two years due to abortion, or
912 a year. Since these states comprised 26 per cent of the Birth-
registration Area of the United States, we have 3,508 abortion deaths
annually in the United States. (912 -r .26 = 3,508.) This number
must be corrected by the addition of abortion deaths reported to the
coroner and classified as homicides (approximately 5 per cent) ; and
by the fact that the area covered in the Children’s Bureau survey
is 36 per cent urban and 64 per cent rural compared with the
general average for the United States of 42 per cent urban and 58

DEFINITION AND SCOPE

per cent rural. These two corrections would bring the recorded abor¬
tion deaths for the entire country to not less than 4.000.

In the search for concealed abortion deaths methods have recently
been suggested by German statisticians. There is no question that
every person dying of abortion has on file somewhere a death certifi¬
cate. The question is: Under what disease was this death classified?

The extravagant statements concerning abortion deaths in Germany,
running up to 50,000 deaths and 1,000,000 abortions, led the Prussian
Bureau of Vital Statistics to analyse all deaths for the year 1927 to
see what was the maximum possible that could be ascribed to abor¬
tion. Since the total number of women who died annually in the
childbearing period was less than 60,000, it was evident that 50,000
deaths from abortion was a gross exaggeration. Consequently they
sought to compare the deaths in females of ten to fifteen years of age
with those in the childbearing period of fifteen to fifty years. Since
the period of ten to fifteen years is that in which there is the lowest
mortality, comparision is made with it under the various classifica¬
tions for causes of death. Tuberculosis, cancer, influenza and other
well-defined diseases could be eliminated. Of the remaining causes
such as diseases of the heart, lungs, nervous system, digestive tract,
urinary organs and “unknown” factors, it was assumed that if one-
lialf of the additional deaths from these causes in the years between
fifteen and fifty were attributed to secret abortion deaths, it could be
considered a maximum . Such possibly concealed abortion deaths
amounted to 3,500 for 1927 in the state of Prussia. The actual regis¬
tered abortion deaths were 1,476. Including a few other sources,
a maximum figure was finally estimated as 5,100 annual abortion
deaths in Prussia, which would correspond to 8,300 for all of Germany.

A similar method of comparing vital statistics to detect abortion
deaths was suggested by Freudenberg. He compared male and female
deaths during the period of fertility (15-50 years) in Prussia for 1927.
This analysis showed that the only places where appreciable difference
between the sexes appeared that could be attributable to abortion
deaths were under the heads of lung, cardiac, and genito-urinary dis¬
eases. Taking the total of these differences, he found only 1,508
deaths that could in any way be classified as possibly due to abortion.
Freudenberg 7s maximum of concealed abortion deaths, adding the
1,476 registered deaths, amounted to only 3,000 for Prussia, or 5,000
for Germany as a whole, as compared with 8,300 by the other method.

This latter method of computation seems to me well worth follow¬
ing in this country. If we assume that the results would be similar,

ABORTION

the 4,000 abortion deaths registered annually would be about doubled
by the addition of the concealed deaths, making’ an 8,000 total.

Let us see now how our original formula works out :

Abortions times Mortality Bate equals Abortion Deaths
681,600 x 1.2 per cent = 8,179

With such a close similarity in the results obtained by different
methods, we can assume, I believe, that we are not so far from the
truth.

It will be noted that the number of abortion deaths is materially
lower than the figure 15,000 that I gave in earlier reports, but I am
convinced that my previous estimates were too high. A maximum
of 10,000 abortion deaths in this country is nearer the truth. There
is no need for exaggerating this number. It is sufficiently appalling
that 8,000 to 10,000 young women lose their lives from this cause every
year. Exaggeration merely weakens the plea of those who are seek¬
ing to find means to reduce this waste of life. If reinforcement is
necessary, let the reader reflect that for every woman who dies as a
direct result of abortion, several women are disabled, sometimes per¬
manently, or are rendered sterile, or at a subsequent pregnancy suffer
from the after effects of the abortion.

Purpose of This Book

From the analysis of the outline as given, it will be evident that I
had in mind a monograph which should not merely help the prac¬
titioner and specialist in medicine in the diagnosis and treatment of
the various forms of abortion and its sequelae, but which would also
give to the sociologist and the student of public health, the facts
necessary to understand the way in which abortion undermines the
physical well-being and moral integrity of the community.

Twenty-five years ago my small volume entitled, “ Prevention and
Treatment of Abortion ” was limited almost entirely to the medical
phases of the question. I did, to be sure, briefly suggest at that time
the possibility of exerting some control over the spread of induced
abortion, by the prevention of conception, but this phase of the ques¬
tion was given scant consideration.

Since that time the frequency of induced criminal abortion has
greatly increased. Hence from the standpoint of preventive medicine,
we can no longer be content to take up merely the treatment of the
pathologic conditions that have resulted from such abortions, but
must give thought to the underlying social conditions that have made
so many of our young mothers willing to resort to this dangerous

DEFINITION AND SCOPE

procedure. Only by looking- at our problem from this broader angle
can we as physicians be said fully to have done our duty. I know of
no condition in medical practice in which the effort to limit its fre¬
quency is so intimately bound up with the social and moral life of
the people. To some extent the spread of venereal diseases is influenced
by these same factors but their control, owing to their bacterial origin,
is relatively simple compared to the complexities that attend limita¬
tion of a procedure like abortion that may be practiced in any home
at any time.

A further justification for this monograph lies in the fact that as
far as I know no one lias thus far attempted a comprehensive review
of the entire subject. Textbooks on obstetrics have as a rule failed to
give even the strictly medical phases sufficient attention. Although
one out of every three or four pregnancies terminates in abortion,
only about one-twentieth of the space in books on obstetrics is ordi¬
narily devoted to its consideration. The same criticism would apply
to the teaching in medical schools. There are numerous monographs
published in Germany, England and this country, dealing with such
special phases as therapeutic abortion, statistics of abortion, legaliza¬
tion of abortion, methods of induced abortion, etc., but I know of no
volume that tries to embody the subject as a whole.

Finally, it has been my purpose to give without bias or exaggera¬
tion all the essential information on this subject that is at present
available. There are many empty pages for future generations to fill
in. An illustration of this was just given in discussing the frequency
of abortion. Many important questions dealing with the causes of
spontaneous abortion remain to be solved. The treatment of septic
infections, especially those due to the streptococcus, is still in its
infancy. The safest method of therapeutic abortion is a matter re¬
quiring additional study. Sociologic experiments such as the legali¬
zation of abortion in Russia, require further analysis before coming
to conclusions. I trust I have been impartial in my discussion of the
medical and sociologic suggestions that have been made. If at times
my advice is somewhat dogmatic, especially regarding the medical
treatment of abortion and its various complications, that has been
for the purpose of presenting the subject more clearly to the general
practitioner, for whom this book is primarily intended.

The needless wreckage of human lives that comes as a result of this
scourge of abortion is a problem of the first magnitude and the chief
responsibility for its correction lies at the door of the medical profes¬
sion. If the ridiculous and contradictory laws at present on our statute
books are to be corrected, if governmental agencies are to be made

ABORTION

to realize their failure properly to provide maternal care and suitable
home conditions for poor mothers with large families, if a more hu¬
mane attitude is to be taken regarding the limitation of offspring and
the medical indications for abortion, it is the duty of the doctor to
blaze the path of reform. Every day evidence of the misery and ill
health that follows upon abortion comes to our attention. No other
group is in a position to appreciate as we do the damage it inflicts
upon the integrity of the family. If we as physicians wish to retain
public confidence and respect, we must assume our obligations in this
matter. The prevention and control of abortion vitally concerns the
health of the community, and while the actual carrying out of the
necessary changes must be left largely to governmental agencies, to
law makers and to social workers, the direction and control should
be placed in the hands of the medical profession. It is my hope there¬
fore that by presenting the subject from its wider medical and social
aspects this monograph may prove of some value in stimulating
thought and furnishing data that may serve as a basis for a program
of revision.

CHAPTER II

HISTORICAL AND RACIAL ASPECTS

i\ S PAR BACK as human records can be traced there is evidence
** of the desire of the race to maintain some control over the num¬
ber of offspring. The interest in this problem was often acutely
emphasized by some catastrophe that interfered with obtaining the
necessary nutrition and shelter for the family. Anthropological ac¬
counts are replete with the abortifacient practices of primitive peo¬
ples. No one who has not surveyed these practices has any conception
whatever of the gruesome, awful nature of the pain-inflicting processes
by which the fetus was expelled, leading not infrequently to the
ultimate death of the mother. Witkowski and Ploss-Bartels — to men¬
tion only two of the surveys and to omit hundreds of anthropological
observers who have dealt with abortion among primitives — give
graphic accounts of methods employed; Witkowski rs record is fully
illustrated.

While the physical means were more spectacular, the nostrums to
be taken ineffectively by the mouth were more frequent and varied.
The belief in their efficacy is often a result of the failure of the primi¬
tive mind to think scientifically; that is, in terms of cause and
effect. Of course, the primitive did not have the advantage of our
accumulated experience. As in the instance of early contraceptive
ideas, abortive procedures were not infrequently based upon symbolic
magic : if something slippery were eaten the fetus would slip out of
the uterus. What could be simpler or more logical?

Himes has called attention, in his forthcoming “Medical History
of Contraception,” to what he believes to be the oldest abortifacient
recipe still extant in writing. It is more than forty-six hundred years
old, and dates from 2737-2696 B.C. In a famous Chinese herbal,
“Chung Lsiu Cheng Ho cheng lei pen ts’ ao,” written by T ’ang Shen-wei
about A.D. 1108, reference is made to shuh yin , or mercury, as causing
abortion. While this herbal dates from only A.D. 1108, it is of great
significance that the recipe (for full text, see Himes) is quoted by
T’ang Shen-wei from the “Shen-Nung pen ts’ ao ching, ” the most
ancient medical work in the Chinese language. It is attributed to
the Emperor Shen Nung who, according to Chinese chronology, reigned
in 2737-2696 B.C. If a recipe in writing is as old as this, how old must

ABORTION

the practice be? The answer is: nearly as old as the social life of
man. This throws a flood of light upon the difficulties that must at¬
tend its social control in our times.

The age of abortion being what it is, we ought not to be surprised
to find it mentioned in the literature of the ancient Hebrews, Egyptians,
Greeks and Romans.

In old Babylonian scripts there was no interest in the induction of
abortion, but mention is made of various factors that tend to bring
on a premature interruption of pregnancy. This was said to be due
to evil spirits, who could be driven from the body of the expectant
mother by incantations and thus enable her to carry the child to term.
In Egypt the famous Ebers Papyrus gives directions as to the man¬
ner of producing an abortion, an indication that this procedure was
well known to the Egyptians.

The Jewish race from its earliest days stressed the importance of
increasing its numbers so as to become more powerful. Evidence of
this is manifest in Genesis (Cli. i, 22), where we find the command
“Be fruitful and multiply,” and later (Ch. xxii, 17) where the Lord
speaks to Abraham, saying “That in blessing I will bless thee, and in
multiplying I will multiply thy seed as the stars of the heaven, and
as the sand which is upon the sea shore.” Those who interfered with
these commands were to be punished. According to Josephus, the
Jewish law declared that all women were to be punished if they pro¬
duced an abortion. If the child was killed at birth it was to be re¬
garded as similar to murder. Where the Jewish race came in contact
with the traditions and customs of the Greeks a greater laxity was
observed in regulations restricting abortion.

Coming to Greek civilization, we find that Hippocrates mentions
softening of the breasts as an indication of threatened abortion. In
such cases he ordered parsley, which produced gas, and was therefore
good for the pregnancy. Oppressive weather was supposed to have
an unfavorable influence. During this epoch, the greatest intellects
favored the limitation of offspring and, if necessary, advised the in¬
terruption of pregnancy in order to keep the race in the best social
and economic condition. Plato and Aristotle clearly picture the moral
standard of the time on these matters. Aristotle says : “ If it should
happen among married people that a woman, who already had the
prescribed number of children, became pregnant, then before she felt
life, the child should be driven from her.” Each state should pre¬
scribe the suitable number of offspring, and see to it that thereafter
abortions are induced.

HISTORICAL AND RACIAL ASPECTS

Plato desired that his republic should not consist of more than
“five thousand and forty” citizens, and, in order to maintain a bal¬
ance of this number, he recommended the limitation of births. He
wished to make obligatory the abortion of every woman who con¬
ceived after her fortieth year. According to both Plato and Aristotle
an abortion could be effected before life Avas felt without punishment
The ancient Greeks in fact, were in their philosophy true Malthusians.
Hesiod counselled that parents have but one son similar to the recom¬
mendations of Plato, Aristotle, Lycurgus and others. The attitude of
the Greeks at this time is exemplified by the satirical epigram : “There
is nothing more unfortunate than a father, unless it be another father
who has more children than lie.”

When Ave compare the Avritings of the philosophers with those of
Hippocrates and other physicians of that time we meet with a con¬
trast that is not unlike that found between sociologists and physicians
of the present day. Hippocrates in his medical practice saAv much of
the injury to life and health produced by efforts to produce an abor¬
tion. While on the one hand he Avas willing to permit and even to
advise certain women as to a simple method of interrupting preg¬
nancy, he Avas opposed to putting agents for this purpose into the
hands of the laity.

Some contradiction is found between the Hippocratic oath accord¬
ing to which the use of abortifacient bougies and pessaries Avas de¬
nounced, and the instructions given by Hippocrates to a harp-player
who desired to end her pregnancy. He advised this young lady to
jump in the air, striking her heels against her hips. She followed
his advice, and after the seventh (magical number) jump promptly
aborted. Apparently Hippocrates considered abortion as a rather inn
proper but necessary expedient in many cases. In the following
century Aspasia gave a complete list of abortifacients, and also exact
instructions as to the prevention of conception. Much stress was laid
upon whether or not life had been felt. No one in Greece had any
moral compunctions about committing an abortion during the first
half of pregnancy.

As to the various causes of spontaneous abortion, Hippocrates in
his Aphorisms cites many forms of external physical violence that
may produce an abortion. Fever, vomiting and abdominal pains may
bring on such an expulsion of the ovum. Excessive or too little nour¬
ishment, the ingestion of something bitter in the food may lead to an
abortion. He warns against drastic purgatives and blames certain
conditions of the uterus in which the opening is too large or the organ

ABORTION

itself too heavy and dense. Habitual abortion Hippocrates attributed
to insufficient development of the uterus, Some of these factois aie
accepted even today as causes of abortion.

Some knowledge of pathological anatomy of early pregnancy was
obtained by Hippocrates through the examination of embryos that
were expelled by the public women of the city, in whom the practice
of abortion was universal, owing to the necessity of maintaining their
trade. Two of the embryos were preserved in the Hippocratic collec¬
tion, and were described as resembling a raw egg whose outer mem¬
brane contained white and thick fibers. In the center of the jelly-like
sac was something small which resembled an umbilical cord. As to
the symptoms of abortion, Galen speaks of the pains and bleeding,
while Hippocrates calls attention to the reduction in the size of the
breasts as a sign of fetal death.

An interesting and complete monograph dealing with the subject
of abortion in Greek antiquity was written by Dr. Moissides and pub¬
lished in 1922 in Janus. Here one can find twelve pages of various
abortifacient drugs employed by the Greeks. The failure of such
drugs and violent physical exercise as recommended by Hippocrates
to produce results, led to the employment of various methods of in¬
strumentation and intrauterine injections (Fig. 1). Two sorts of
pessaries were mentioned, one resembling our modern suppository,
which was inserted in the vagina, and the other resembling a tampon
consisting of a sponge or cloth soaked in some suitable medicine with
a string tied to it so that it could be removed more readily.

In the days of the Roman consuls abortion was rare, but in Imperial
times it grew without restraint. No class was free from self-indul¬
gence in this and other matters. History relates that Julia, the niece
and concubine of the Emperor Domitian, having conceived as a result
of her imperial love, induced an abortion, and lost her life in conse¬
quence. One of the frequent causes of abortion dating back to primi¬
tive times was the desire of the women to retain the beauty of their
figures. For this reason Seneca praises his own mother as one who
had never followed the customs of the day in trying to retain her
shapeliness at the expense of killing her offspring, but rather as one
who was proud of her fertility. To be sure, the father was alone
permitted to set the indication for an abortion and if, as in the case
mentioned by Cicero, a woman committed an abortion in order to
get a larger share of her husband’s property, she was punished by
death as one who had willfully denied her lord the pleasure of par¬
enthood.

HISTORICAL AND RACIAL ASPECTS

Some indeed declaimed against the degeneracy of the times. Thus
Gellins says “Dost thou believe that nature gave women breasts as
graceful elevations intended to beautify the body rather than to

Fig". 1. — Greek abortion instruments.

nourish the child? The majority of these terrible women seem deter¬
mined to dry out and extinguish these holy sources of human life.
The same craze drives them to employ evil medicines to destroy the

ABORTION

offspring in their womb so that their abdomen may retain its smooth
surface, unwrinkled and unchanged in form by pregnancy and labor.”
The dangers of criminal abortion were generally recognized, and many
instances of resulting death are recorded in literature. The richer
classes were particularly tainted with this vice so that Juvenal gives
this advice to husbands: “ Rarely does one see a woman confined upon
a golden bed. Medicine and other measures bring this about. Be
satisfied, unlucky one, and care not what drink it may be, hand it to
the lady, for should she perchance become a mother, your son might
prove dusky-skinned and a black would inherit your wealth.”

The influence of the Christian disciples and of the Jewish teachers
in the Talmud tended to combat the looseness of the family ties and
the destruction of offspring. Becky and Carr-Saunders have empha-
sized the important service of Christianity in correcting the tendency
to abortion. The former says: “The practice of abortion was one to
which few persons in antiquity attached any deep feeling of condem¬
nation (p. 22). . . . The language of the Christians from the very
beginning was very different. With unwavering consistency and with
the strongest emphasis, they denounced the practice, not simply as
inhuman, but as definitely murder. In the penitential discipline of
the Church, abortion was placed in the same category as infanticide ;
and the stern sentence to which the guilty person was subject im¬
printed on the minds of the Christians, more deeply than any mere
exhortations, a sense of the enormity of the crime (23, 24). . . . The
moment, they taught, the fetus in the womb acquired animation it
became an immortal being, destined, even if it died unborn, to be
raised again in the last day, responsible for the sin of Adam, and
doomed, if it perished without baptism, to be excluded forever from
heaven and to be cast, as the Greeks taught, into a painless and joy¬
less limbo, or, as the Latins taught, into the abyss of hell. . . . That
which appealed so powerfully to the compassion of the early and
medieval Christians, in the fate of the murdered infants, was not that
they died, but that they commonly died unbaptised ; and the criminal¬
ity of abortion was immeasurably aggravated when it was believed
to involve, not only the extinction of a transient life, but also the
damnation of an immortal soul” (p. 25).

Apparently the Christian Church took over much of the morality
and customs of the Jews regarding the limitation of offspring. St.
Augustine leaves no question in his writings as to the classification of
abortion as murder. The belief in the necessity of baptising the un¬
born child was an added reason for rigid denunciation of any abortifa-

HISTORICAL AND RACIAL ASPECTS

cient. Yet among the powerful Church Emperors of Rome abortion
was not only tolerated, but practiced almost as freely as in Pagan
times.

An interesting observation comes to us from the writings of Pris-
cianus, who toward the end of the fourth century declared: “No one
has the right to prescribe any means for producing an abortion. A
physician should not burden himself with this sin. Only where the
uterus is diseased or where the mother is exposed for other reasons
to danger through pregnancy, is an abortion permissible. . . . Just
as it is sometimes of advantage to remove the dry twigs of a tree in
order to save the whole tree or as a heavily laden ship may find it
necessary in a storm to throw overboard some of its cargo in order
to prevent a shipwreck.’7

The tribes from Northern Europe that overran the Roman Empire
looked with disfavor on any diminution of their number through
abortion. The Visigoths punished abortion by death of the respon¬
sible party. The Alamanni punished abortion before the sex was
determined with a fine of 5 soldi; later if it was a male the fine was
12 soldi; if female, 24 soldi. On the other hand, the unwanted child
was often gotten rid of by leaving it in the woods to starve and die.

From Arabian sources we learn that Avicenna (979-1037) in his
“Canon of Medicine” advised against bathing during the first half
of pregnancy, because it frequently caused an abortion. He discussed
the propriety of inducing an abortion in cases of contracted pelvis.
For this purpose he suggested lifting heavy objects, venesection, in¬
troduction of pieces of wood or rolls of paper into cervix, besides numer¬
ous medicines. He even devised a special instrument with a long nozzle
for injecting substances into the uterus. In the following century
Abulkasis, a Mohammedan physician living in Spain, denounced the
tendency to criminal abortion on the part of the populace. If such an
abortion should really be indicated, lie advised calling in a skillful
midwife for this purpose.

In the days of the Renaissance, the morality of the Church was cer¬
tainly very loose; nevertheless, we find the Diet of Worms (1521)
declaring murder and criminal abortion to be equally punishable.
Kings were equally insistent upon severe punishment. Crucifixion
was a common way of putting these women to death. In contrast to
this cruel punishment of the poor, the wealthy man or woman respon¬
sible for such a deed would merely have to pay a sum of money for
his absolution. During medieval times philosophers held that every
fetus possessed an immortal soul, and hence an abortion was to be
punished equally with murder. Only the Jesuits were inclined to hold

ABORTION

out against the harshness of this judgment. Pope Innocent XI in
his Bull against the Jesuits accused them of inducing abortions in
cases of illegitimate pregnancies.

Ethnological Aspects

Apparently there is to some degree a racial predisposition to spon¬
taneous abortion. In some countries it appears that no amount of
severe physical labor by pregnant women brings on interruptions of
gestation, while in others abortions frequently result therefrom. Among
the lower classes in China, women row for long periods of time upon
the river, yet rarely do any of them abort. In Persia women ride long
distances astride their horses without ill effects of this sort.

On the other hand, while in some Indian tribes women can appar¬
ently do heavy work without aborting, this is not true in others. We
find that the women of New Zealand, parts of Australia and East
India have abortions very readily. Particularly among races where
it is customary to employ one form or another of massage during
pregnancy do we find abortion or premature labor occurring very
often. This is true of some Mexican tribes who employ a midwife to
massage the abdomen from the seventh month on to bring about a
favorable presentation of the child. In Java also the extremities are
pulled and the abdomen squeezed in the course of massage.

In Tunis and Turkey the custom of taking very hot baths leads to
an increased frequency of abortions. In Turkey we must also con¬
sider the rough management of confinements as predisposing to sub¬
sequent abortions. The wealthy women in China owing to the de¬
formity of their feet lead a sedentary life and have but little resistance
to an abortion. Hence it occurs among them very frequently in con¬
trast to the poorer Chinese women. Countries where malaria and
other tropical fevers are common show a much larger percentage of
abortions than more northern countries. The most important cause
of abortion among uncivilized as well as civilized races is that brought
on by the individual directly or through some agent. Such artificial
or criminal abortion will be taken up later on in this chapter.

Spontaneous Abortion

The ancient Roman women used to offer flowers to Juno, in her
temple on the Esquiline Hill, to keep them from having a miscarriage.
Most of the methods used nowadays by the uncivilized nations of the
world to prevent an abortion have magic as their mainstay. Armlets
of all kinds have been used for many generations. The Talmud speaks

HISTORICAL AND RACIAL ASPECTS

of tlie eagle stone worn by pregnant women. In the Atharva-Veda
of ancient India a magical incantation was spoken to the goddess
Prcniparni to drive away the demon, Kanva, who eats the embryo.
In Borneo the natives fear a terrible little demon, KanKamiak who
gets into the bodies of children still in their mother’s womb. In the
province of Anam (French Cochin-China) abortion is supposed to
be due to the spirit Con Ranh. The form of incantation by which this
evil spirit is driven away is thus described by Landes : Two dolls are
made of straw, one to represent the mother, the other the child. Usu¬
ally they are placed together in some natural position, such as the
mother holding the child in her arms or nursing it. Then some person
who will act as a medium is sought, and the priest begins to make
passes and manipulations over him similar to those employed in
hypnotism. The medium is supposed to be animated by the demon
of the aborted children. The priest then questions the demon, de¬
mands that he cease to torment the family threatened by abortion,
and asks that as a pledge for this he give his signature; that is, the
mark of his fingers on a piece of paper. If the demon consents, the
medium dips his hand in ink and presses it upon the paper. If he
resists, he is threatened, long needles are thrust through the cheek
of the medium (who is doubtless in a hynotic trance) and almost
invariably he yields at last. Then the two dolls are burnt, concluding
the ceremony.

Another simpler but unscrupulous way of getting rid of the evil
spirit is to take the bedding, clothes and utensils used at the time of
an abortion and place them out somewhere on the highway. Here
some poor woman in need will doubtless find them, and, taking them
home, the evil spirit will go with them and the poor woman will be
the next sufferer from abortion. The very mention of the name of
the evil spirit, Con Ranh, is shunned in the presence of pregnant
woman for fear that thereby he may be called to them and harm them.

In many countries women during pregnancy are given special care
and even to some degree placed in isolation as taboo. In old Calabar
they go to a quiet place away from noise and evil eyes until they are
confined. Intercourse was absolutely prohibited at such times by some
tribes, since this was known to be a factor in producing abortions.

Considerable interest attaches to the varying customs of past cen¬
turies and different nations in disposing of the products of abortion.
In his excavations around Troy, Schliemann found the remains of
three small human embryos placed in an urn. They were unburnt
and the skeletons were complete. In view of the general custom of
burning the dead in those times, the preservation of these embryos is

ABORTION

very interesting. Pliny says that it was not customary to burn any
person until after teething. The urn in which these embryos were
found is reproduced in the accompanying illustration (Fig. 2).

The Tews were accustomed to bury their abortion embryos, but, before
doing so, careful examination was made to determine the sex for
ritual purposes. In this way many interesting embryological and
anatomical observations were made in past centuries. Among these
should be mentioned the abortion ovum, from the third month of
pregnancy, depicted by Ulysses Aldrovandi of Bologna (Fig. 3).

In the Murray Islands north of Australia it is customary to dry the
aborted embryo, and hang it in the wind. Occasionally its body is
painted. In Siam it was thought that evil magic might be done with

Fig-. 2. — Urn used for preserving- embryos found in excavations around Troy.

Bartels. )

(Ploss-

such an embryo, hence it was taken to a priest, who put it in a pot
and carried it to the river into which it was thrown, after suitable
incantation. This superstition of magic wrought by embryos we also
find in European countries. Hungarians and Rumanians in the region
of Siebenbuergens cut off the little finger of the left hand of the
embryo and put it in the foundation of a new building to ward off
lightning. Whoever cuts it off can see in the dark and he himself is
made invisible. Hungarian gypsies used the blood of such embryos
together with the sexual organs of a male and female dog, to make
a salve. This salve, it was claimed, would if rubbed on their hands,
make them successful in their robberies. If the gypsy wished to steal
a horse, he rubbed the salve on the inner side of his thighs before
mounting the animal.

HISTORICAL AND RACIAL ASPECTS

Induced Abortion

In discussing tlie history of abortion it was shown that the practice
of interrupting pregnancy dates back to the earliest times. It is
equally true that the practice is to be found in every corner of the
globe at the present time. Almost no tribe is so primitive as not to
know some means of bringing on abortions.

Fig-. 3. Abortion ovum of three months’ pregnancy, depicted by Ulysses Aldrovandi of

Bologna. (Ploss-Bartels.)

Starting with the savage races on this side of the Atlantic we find
in Paraguay that certain tribes have almost died out as a result of
systematic abortions. Guaycuru women for generations refused to
bear children until over thirty years of age, so that only four persons
were left of this tribe early in the nineteenth century. Among the
Mayas it was the custom to make the naked pregnant woman lie down

ABORTION

upon lier back, and then have two old women beat upon her abdomen
until blood began to flow from the vagina. Many lost their lives as
a result of such procedure.

Along the Orinoco River, tribes have been greatly reduced in num¬
ber, owing to the frequent use of abortifacient herbs. The Jesuit
priest, Gili, who lived among these people for fifteen years, related
that the women determined the number and time of their pregnancies
in accordance with one of two systems. One set of women, the ma¬
jority, believe that it is better to remain young* and beautiful by post¬
poning pregnancies until late in life. The others, on the contrary,
think it best to become a mother as early as possible, since this added
to health and happiness. Humboldt, on his visit to this country, de¬
scribing these conditions, remarked that the ecbolic drugs employed
by the natives apparently were effective and did but little harm. He
hoped that Europeans would not learn to employ them.

North American Indians do not have large families, but in some
tribes, the Chippewas for instance, there is a strong feeling against
abortion. The Dakotas, according to Schoolcraft, employed various
herbs as ecboiics that often resulted in the mother’s death. One Crow
Indian squaw at the age of forty-five had committed 33 abortions.
In some districts the practice seems to be based largely on economic
conditions. It seems questionable, however, if the small number of
children among the Indians is not due more to natural abortion and
to a high infant mortality rate than to induced or artificial abortions.
Engelman claimed that the interruption of pregnancy among Indians
was due to bad influence of the invading Caucasians. In the days
of Columbus, however, Las Casas already found the Indians on the
Island of Cuba using herbs as abortifacients.

Among the negro tribes in Africa many travelers found evidence of
criminal practice. This was due, among the Abyssinians, to the law
compelling fathers to kill their unmarried daughters, should the fact
become known that they were pregnant. In Algeria we still find
booths in the public squares where Jewesses sell abortifacient drugs
and instruments. The dying out of the Hottentots seems to be largely
due to the practice of criminal abortion. The Wabunis in East Africa
did away with pregnancy in order not to interfere with their wander¬
ings from one district to another. Among the Hereros abortion was
effected usually by external means such as bloAvs with fists and stones.
Among the Senegalese, abortion was brought on by herbs, by mechani¬
cal means and by wild dances in which the extreme rotation of the
pelvis and abdomen played an important role.

HISTORICAL AND RACIAL ASPECTS

Coming to Asia we find the Turks employing abortion upon the
slightest pretext. Practically no illegitimate children are to be found
among them since unmarried women do not hesitate to resort to
abortion when they become pregnant. Up to the fifth month, accord¬
ing to the Mohammedan religion, life does not exist in the fetus, and
abortion is permitted by law. Midwives are employed for this pur¬
pose. In Mecca it is said midwives do not hesitate to interrupt a
gestation at any stage of development. Stronger women are required
to perform repeated somersaults. Women of more delicate constitu¬
tion are given a combination of herbs, the exact proportions of which
vary with different midwives and are kept secret.

In India the natives vary greatly in their attitude toward abortion.
The low caste Hindoos often resort to it, but among the better classes
abortion is looked at askance. The frequency of child marriages leads
to early widowhood in many instances. Not a small number of these
widows are compelled to take up prostitution as a means of earning
a living, and these of course resort to abortion on every necessary
occasion to conceal their irregular practices.

The Ceylonese are said at one time to have resorted to abortion on
the occasion of any pregnancy occurring earlier than the thirty-sixth
year of their life. According to De Moriez a similar custom exists
among the natives of the Island of Formosa. The Chinese on the
other hand are not addicted to abortion, and hence have a goodly
number of full-term pregnancies, but because of their high death rate
have a nearly stationary population. Among the islands of the Pacific
and the Indian Oceans there are no such compunctions against inter¬
fering with pregnancy. The Japanese concubines of foreigners pre¬
vent the birth of offspring by whatever means seem necessary. A
favorite method of abortion among them is the introduction of a
wooden stick into the uterus similar to that employed by natives of
the Hawaiian Islands (Fig. 4). In Burton’s “ Anatomy of Melan¬
choly” (1621) we find a reference pointing to conditions in the
Orient at this time: “In Japonia ’tis a common thing to stifle their
children if they be poor, or to make an abort.”

Among the women of New Caledonia a safer but less effective
method is used. Stewed green bananas served hot are supplied the
pregnant women, who are said to abort as a result of this concoction.
On the Island of Formosa the abortions done upon all women up to
35 years were brought about by nuns who belabored the abdomen
of such women with their feet. Among the Sandwich Islands a
conjurer effected rupture of the membranes with resulting abortion

ABORTION

by means of a bamboo stick. Andrew found many childless families
on these islands as a result of these abortions, the exact number being
23 out of 96, or 25 per cent.

In many instances civilization has led to the substitution of criminal
abortion for infanticide. The Yiti Islanders consider it a disgrace
to have too many children, and, in order not to be ridiculed, often
resort to an abortion. In Malacca, women who resorted to abortion
could be severely punished. If caught, they were severely lashed and
if they happened to die as a result of this beating, the husband was
exonerated. In view of the custom among the primitive men of

Fig-. 4. — Hawaiian abortion stick with g-oclhead carved in one end. (Ploss-Bartels. )

Borneo to shelve any concubine after the arrival of her second child,
the women resorted to abortion very often to retain favor with their
husbands.

Among the more civilized races of men in modern times the practice
of induced abortion is widespread. The teachings of the Catholic
Church have doubtless had some effect in reducing the number in
those countries where this faith predominates, but this reduction has
been relatively slight, so that throughout the past fifty years there lias
been a steadily rising frecpiency of abortion throughout the civilized
world. Detailed figures concerning this increase will be given in Chap¬
ter XXIII on Statistics. Economic and social factors have been largely
responsible for the growing prevalence of abortions. The most im¬
portant of these factors are :

HISTORICAL AND RACIAL ASPECTS

(1) Increasing secularization of thought, increasing hedonism and
pleasure philosophy of life, urbanization and the frantic desire to
raise the economic standard of life by limiting offspring by any means,
however desperate.

(2) Cultural lag: the resistance to change, responsible for the
slowness in diffusing reliable scientific contraceptive knowledge.

From this brief review of the history and ethnology of abortion we
can appreciate what a dominant factor has been the practice of abor¬
tion in the life and happiness of the human race. Many have tried
to lay down formulae for the limitation of offspring, but have failed
to recognize the inherent physical dangers and possible moral de¬
terioration associated with measures that give unbridled rein to the
interruption of pregnancy. On the other hand, we have ample evi¬
dence that where economic necessities in the form of the mother's
occupation, the lack of proper nourishment, the constant wandering
of a nomad life, have made it impracticable to carry through another
pregnancy, or when false ideals of beauty have been prevalent, human
beings have not hesitated to produce abortions.

In the last analysis, religion has helped to bring about an abatement
of the unbridled practice of abortion rather through its efforts to hold
high the ideals of maternity and the love of children than by its strict
denunciation of those who, under special circumstances, seek abortion
as a means of preserving the honor and health of the family. In the
same way the State has gained but little by its strict efforts to punish
abortion, particularly since the rich and powerful escaped scot-free
while the poor were crucified. It is difficult to find positive evidence
that the practice of abortion in the past centuries has led to a serious
deterioration of the race, in spite of the many statements to that effect
in books of history. Nor, many statements to the contrary notwith¬
standing, is there irrefragable evidence that any ancient civilizations
“fell” — was their heritage not handed on to us? — because of fre¬
quency of resort to abortion. Such views are often the result of
wishful thinking; they are too frequently an attempt to bolster up
preconceived theological opinions by the use of limited and false
interpretations of history.

CHAPTER III

ABORTION IN ANIMALS*

By Walter Long Williams

IT IS DIFFICULT to define abortion in domestic animals in a wholly
acceptable manner. Courts have held that an animal known to
have in its organs Bacillus abortus (Bang) has a dangerous contagious
disease, but the decision rests upon the presence of the bacillus, not
upon the occurrence of abortion.

Herbivorous domestic animals are adeciduate. When an ovum dies
in early gestation it lies free within the uterine cavity. In uniparae it
may be resorbed or expelled unseen ; in multiparae it is usually re¬
sorbed or undergoes papyraceous desiccation. It is only rarely that
the expulsion of an equine or bovine fetus of one or a few centimeters
in length is observed, because when the sac containing the fetus has
appeared at the vulva, it is but a few minutes until its expulsion has
been completed and the ovum has disappeared. There is no retention
of the placenta, no hemorrhage, or other clinical evidence of disease.
The failure is first recognized by the occurrence of estrus, and the
phenomenon is designated sterility.

Apparently borrowing from human medicine, veterinarians some¬
times include in their definition of abortion the expulsion of a living
fetus not sufficiently mature to survive. I have not observed such a phe¬
nomenon. It may occur in multiparae when the death of some of the
young occasions the expulsion of all, including living individuals, but
the rule is that the dead fetuses are retained until all have died or
some have matured, and all are expelled together. Non-viable young
are common in all species, but their non-viability is dependent upon
mortal disease of intrauterine origin. There is no uniformly accepted
line of demarcation between physiologic and pathologic duration of
gestation, especially in horses and cattle. The ideal duration of bovine
gestation is usually placed at 275 to 285 days. Passing beyond these
limits in either direction, the ratio of dead to living fetuses expelled
increases and the viability, vigor and value of the living young de¬
crease. Abbreviated gestation is very common, and prolonged preg¬
nancy infrequent. The ideal duration of gestation of the mare is
fixed by von Oettingen16 at 315 to 320 days with living foals born

'‘‘For references, see end of chapter.

ABORTION IN ANIMALS

at 300 to over 365 days. Abbreviated gestation, with 2 living foals,
is quite rare, while prolonged gestation is very common, and the
greater the prolongation, the higher the ratio of dead fetuses or non-
viable living foals. Any effort to distinguish between abortion and
stillbirth is without practical importance. The earlier a dead or mor¬
tally diseased fetus is expelled, the better for the subsequent sexual
health of the female.

An acceptable definition of abortion is further complicated by the
variation in parity. Domestic animals include the definitely uniparous
mare and cow ; the equally multiparous swine and carnivora ; and the
goat and ewe, somewhat suggestive of biparity. The ovaries of the
pregnant sow commonly have more corpora lutea than there are
fetuses in the uterus, and there are often present dead embryos in
varying states of development, disseminated among living ova.

Under the conditions, abortion, as used in this chapter, will signify
the observed expulsion of a dead fetus , or fetuses , promptly following
its, or their, death. Under this definition, abortion is preeminently a
phenomenon of uniparae. Once a uniparous fetus has died, abortion
is the safest route toward the recovery of the affected female. The
dead uniparous fetus is not always aborted. It may undergo macera¬
tion with great peril to the life of the mother, or if she survive, her
breeding life is almost certainly closed. In the cow, but in no other
domestic animals, a vast interplacental hemorrhage not infrequently
occurs, completely enveloping the fetal sac in an immense blood
coagulum. The mass does not undergo putrid decomposition; the
blood serum, the fetal fluids, and the fluids of the fetal body are re¬
sorbed and a specific type of mummy remains indefinitely. There
also occurs, so far as known, only in the cow, what I have described19
as a static fetal cadaver, in which the fetus dies and remains inert in
the uterus for an indefinite period, without putrefaction or desicca¬
tion. Each of these is far more destructive to breeding life than
abortion.

In sharp contrast, there is often observed in fhe sow one or several
fetal cadavers which are retained and undergo a non-toxic and non¬
irritant papyraceous mummification, with retention of the cadavers
until term, when they are expelled along with several or many viable
young, thus conserving reproduction. Papyraceous mummification
is also observed, though rarely, in twin pregnancy of uniparae, in
cases where the chorionic sacs of the twins do not fuse. Hence, abor¬
tion, once the fetus has died, becomes a conservative process in uni¬
parae, and a destructive phenomenon in multiparae.

ABORTION

The Basic Causes of Abortion

Artificial abortion is readily induced in the cow by means of the
dislodgment of the corpus luteum by digital compression per rectum,
the expulsion of the fetus following in two to three days; or it may
be brought about by removal of the ovary. The corpus luteum of
pregnancy of the cow persists, physiologically, for a considerable
period postpartum, while in the mare, atrophy of the corpus luteum
occurs at mid-term. If the ovary of the mare is removed during the
first half of gestation, abortion regularly follows, while if removed
during the second half, the pregnancy may continue. Apparently
the abortion in the cow is associated with the abruptness of the re¬
moval of the corpus luteum. Pathologically, apparently as a result
of cystic degeneration, the corpus luteum may be destroyed ; estrus
and coitus follow, but abortion does not usually occur, perhaps be¬
cause of the gradual atrophy. Aside from such artificially induced
abortions there are many fundamental factors which, according to
clinical observations, underlie the act, regardless of the nature of the
immediate exciting cause. Some of these merit definite consideration.

(1) Abortion Due to an Imperfect Ovum. — There is interesting evi¬
dence indicating that an ovum may be fertilizable although so im¬
perfect or immature that it is incapable of independent embryological
development. I have elsewhere presented evidence20 which seems to
indicate that the sexless free-martin of cattle is the progeny of an
imperfect (immature) ovum, incapable of independent embryological
development, but able to complete asexual fetal maturity as a parasite
upon a sex-potent twin, owing to fusion of the allantois-chorions and
the establishment of a communal circulation. Nature apparently
abhors sexless progeny in mammals, and unless a communal blood
supply can be established with a physiological ovum, sexless, and
anidian ova perish. Bovine twins usually have a clinical history of
genital disease prior to the twin ovulation; most notably the twin
ovulation follows nymphomania, an ovarian disease characterized by
cystic degeneration of ovisacs, commonly involving two or more ovi¬
sacs simultaneously or in rapid succession. As the cow approaches
health, before ovarian stability has been fully established, she may
discharge two ova in one estrus, one of which is immature but fertiliz¬
able. The chorions of ruminant twins regularly fuse, producing a
common chorion. In the cow, not in the ewe and goat, the twins com¬
monly have a communal circulation. In contrast, in the multiparous
sow, fusion of the allantois-chorions of adjacent ova rarely, if ever,
occurs, and free-martins and anidian monsters are well-nigh unknown.

ABORTION IN ANIMALS

(2) Abortion Due to Imperfect Spermatozoa. — As early as 1923 I
submitted clinical evidence21 that the male not infrequently begets
pregnancies which are destined to be aborted owing to some basic
defect in the semen. Later, W. W. Williams and A. Savage15’ 24 showed
that such abortions were associated with a prevalence of definite
morphological defects in the spermatozoa. Recently Lagerlof10 (Fig. 5)
has carried the investigation one important step further and shown
that the pathologic character of the spermatozoa is basic and referable
to pathological changes in the epithelium of the seminiferous tubules.
Although the workers in the field are few, the evidence seems con¬
clusive that the male, through morphologically defective spermatozoa,
is frequently responsible for abortion (Fig. 6).

(3) Twin Abortion. — Identical twins are not positively known to
occur in domestic mammals. Twin pregnancy in the mare is almost
always terminated by abortion. Data submitted by Errington and
myself7 indicate that twin pregnancy in the mare generally has a
clinical background of pathological ovulation. When twin pregnancy
becomes established, there is a -grossly defective power of placental
adjustment. The physiological single ovum, through its allantois-
chorion, contacts the entire endometrium. So far as known, equine
twins are always bicornual. The ovum regularly becomes located
near the base of the cornu. In twins, the two ova apparently grow
unequally, the more vigorous of the two projecting into the uterine
body and occupying its lumen before the lesser has emerged from
the base of the horn in which it is located. The lesser ovum, upon
its emergence from the cornu, abuts against the greater one, pushes
the body allantois-chorion of the greater fetus before it and becomes
invaginated within the greater sac. The lesser ovum is thus deprived
of any contact with the endometrium of the uterine body, is denied
adequate nutrition and perishes. It may undergo some degree of
papyraceous mummification, but the other ovum soon perishes also
and the two are aborted, grossly unequal in size.

Bovine twins generally have a pathologic background. About 75
per cent are bicornual and 25 per cent unicornua]. In almost all cases
the two or more chorions fuse and have a communal allantoic cir¬
culation; the twins enjoy parallel nutrition, their growth is equal and
when one dies, the other also perishes. In rare exceptions the chorions
may remain distinct, one fetus may die and become papyraceous. In
sheep twins and triplets the chorions fuse, as a rule, but the allantoic
circulations remain distinct. Consequently the twins may vary in
size. They are far more frequently aborted than are singles and

ABORTION

limited dats indie cite that a majority of triplets arc aborted (Fig. 7).
One twin or triplet is frequently born non-viable, in which case, as
a rule, it is the smaller lamb, which had access to the restricted pla¬
cental area.

Fig-. 5. — Spermatozoa from genitally sound and diseased bulls, cl, Spermatozoa
from a highly fertile bull. A (upper right) sperm from a bull of low fertility; a
and l), sperm from sterile bull.

Note 'variations in the morphology of the head and protoplasmic drops on the neck,
considered as evidence of unripe, or premature sperms in a (right). In the sterile
bull the tails of the spermatozoa form a dense coil. (Lagerlof; Acta Path. Scand.,
XIX, 1934.)

ABORTION IN ANIMALS

Veterinary writers have ascribed twin abortion to overdistention
of the uterus, apparently upon the hypothesis that through overdis¬
tention the walls contract and expel the uterine contents. Clinically
this is untrue ; in dropsy of the amnion and allantois, common in dairy
cows, with 100 liters or more of fluid, abortion does not occur, birth is
impossible and obstetric relief is usually not satisfactory. Viewed
clinically, twin abortion is referable to pathologic ovulation, placental
maladjustment and inadequate nutrition.

Fig-. 6. — Spermatozoa from an 18 months old bull, with hypoplasia of genital
org-ans. He had been used for 6 months upon about 20 cows, all of which had either
failed of recognized conception, or had aborted.

1. a, thickened middle-piece ; b, head with narrow nucleus. 2. Enlarged, fused
anterior and posterior end knobs and end ring-. Filiform middle-piece. 3. f, filiform
middle-piece with spheroid swelling- at middle of middle-piece ; e, eosinophilic body sur¬
rounding anterior end of middle-piece. 4. s, spheroid swelling at middle of middle-
piece, within the sheath. 5. s, spheroid swelling of end ring. 6. e, acidophile body
attached to middle of middle-piece. (Williams and Savage: Cornell Veterinarian,
1925.)

(4) Hypoplasia of the Reproductive System. — Not rarely there may
occur, almost wholly in dairy heifers, cases of genital hypoplasia or
juvenile genital organs. These animals are slow to conceive, largely
abort, and those which go to term suffer severely from dystocia, usu-

ABORTION

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ABORTION IN ANIMALS

ally associated with stillbirth, retained afterbirth and other pathologic
phenomena. Solitary cases afford no evident solution of the phe¬
nomena. In a large herd elsewhere described22 I have reliably shown
that the hypoplasia is due to malnutrition of the calf during the milk¬
feeding period, and that the cause lies in the method of the artificial
feeding of dairy calves. Several hundred calves were involved, ac¬
curate data are available for 14 years, and the genital hypoplasia,
difficult conception, abortion, dystocia, etc., have been brought under
satisfactory control chiefly through modifications in the volume of
milk and the method of feeding and handling. While the genital
hypoplasia was more evident at first in the females, when an oppor¬
tunity came to compare the fertility of the males grown under the
original and the modified plan, it became clinically clear that the
sexual development was also repressed in the bull calves.

The evidence in these observations indicates that during the first
six months of the life of the calves, while being fed on milk, the mal¬
nutrition compelled precedence to be given to the maintenance of
physical life, and the maturation of the reproductive system was held
in abeyance. At about the end of the milk-feeding period the heifers
commenced to ovulate and spermatogenesis became established in the
bulls ; the period for the proper development of the reproductive
system had expired, and the hypoplasia became permanently fixed.

(5) Abortion from the Breeding of Immature Animals. — The keen
desire of dairymen for early profits has led to the custom of breeding
dairy heifers when fourteen to sixteen months of age, at which time
they have attained but one-third to one-half their adult size, in order
that they may calve at two years of age. The ratio of abortion in
dairy cattle is about four or five times as great as in beef cattle under
normal conditions. In dairy cattle the abortion rate is far greater
in primiparae, reaching 25 to 50 per cent of the total abortions in
most herds. While the abortion rate in primiparae may range between
25 and 75 per cent or higher, the rate for pluriparae in the same herd
drops to perhaps 5 to 10 per cent. No clear line of demarcation can
be readily drawn between abortions in dairy primiparae due to genital
hypoplasia and those referable to breeding while yet immature. The
problem is best approached indirectly. McCampbell13 in an experi¬
ment with 80 beef heifers, bred 40 to calve at 2, and 40 to calve at 3
years. The presence of juvenile genital organs was apparently ex¬
cluded. The abortion rate was not stated. Later, the superintendent
of the experiment station stated in a personal communication “We
had a great number of abortions among these heifers (i.e., the group
bred to calve at 2 years) and the calves which they did produce were

ABORTION

undersized and the heifers did not produce sufficient milk to take care
of them properly. . . . The heifers never did grow out to their full
size and during the last few years we have been culling out all of
these heifers from the herd.”

A client permitted a colt, supposedly too young to copulate, to con¬
sort with a group of yearling draft fillies, practically all of which
became pregnant and subsequently aborted. Clinical data, so far as
available, distinctly indicate that immature animals abort at a far
higher rate than those that do not start to breed until of adult stature.
Those bred too early largely fail to breed again, their average re¬
productive life is abbreviated, and their progeny are small and weak.

(6) Coitus During Pregnancy as a Cause of Abortion, — Sexually
healthy domestic mammals do not copulate while pregnant. Males
that regularly consort with pregnant females make no sexual advances.
Some pregnant uniparae develop estrus and copulate. In at least
some cases, probably all, the estrus is due to pathologic atrophy of
the corpus luteum of pregnancy, owing, it is suspected, to cystic de¬
generation. In cases observed in the cow the new ovum matures in
the opposite ovary to that from which the pregnancy was derived.
Apparently the coitus does little or no harm. In rare cases abortion
follows closely upon the coitus, but so far as may be determined the
estrus and coitus are subsequent to fetal death and the uterine con¬
tractions associated with estrus cause the expulsion of the fetal
cadaver.

(7) Abortion Due to Excessive Coitus.— In the mating of the most
highly valued domestic animals, hand breeding prevails, and usually
but one, sometimes two, copulations are allowed during a given estrus.
When highly fertile mares and cows are mated with equally fertile
males, conception occurs with a single service, thus limiting coitus to
once a year. In pasture breeding, where the male consorts freely
with his harem of females, coitus ordinarily occurs a number of times
during the estrual period, which in the cow continues for 12 to 24
hours and in the mare for several days.

Excessive coitus in domestic animals is restricted to the male, ex¬
cept in rare cases of genital disease, such as nymphomania. Eco¬
nomic considerations dictate that a valuable sire should serve the
maximum number of females consistent with the maintenance of re¬
productive power. The reproductive strength of a sire cannot be
definitely computed in advance, but there exist certain standards by
which a reasonable estimate may be made. A very common, and
highly dangerous basis of computation is the hypothesis that a stated
male is competent to serve successfully as many females as some

ABORTION IN ANIMALS

famous sire of history. Thus some highly influential authorities ad¬
vise that an adult bull may serve successfully 100 cows. Tu the present
state of health of dairy cattle, a bull makes usually 2 or 3 copulations
per conception, which means, with a harem of 100 cows, 200 to 300
copulations per annum, a sexual load rarely, if ever, carried safely.

So far as known, the most common and inescapable effect of exces¬
sive coitus is a decrease in the number, motility and morphologic
soundness of the spermatozoa, factors which not only decrease the
ratio of pregnancies, but place in peril those conceptions which oc¬
cur. Clinicians conversant with large dairy herds, such as that de¬
scribed by Lothe,11 where two or more bulls are used, are quite
familiar with examples in which a large percentage of the preg¬
nancies by one bull are aborted while those of another sire, mated
with the same quality of cows, are conspicuously safe. So far as
researches have progressed, with the one exception of trichomonas
infection (to be discussed later), the comparative abortion rate of two
bulls in one herd, runs approximately parallel with the ratio of
morphologically imperfect spermatozoa in the semen of each.

(8) Abortion Caused by Too Early Postpartum Conception. — The

corpus luteum of the mare atrophies at mid-term and she is regularly
in estrus at 7 to 10 days postpartum. According to tradition, this is
the most favorable time for re -breeding. In concentrated horse-breed¬
ing districts, where reproduction is pushed to the limit, both sexes
grossly overloaded and the basic laws of sex hygiene flouted, endo¬
metritis commonly follows foaling ; the disease fulminates during the
first estrus, there is a profuse mucopurulent genital discharge, and the
nursing foal often suffers from acute diarrhea. According to the
limited data available, mares which recognizably become pregnant
from breeding at this period, abort three or four times as frequently
as those which do not conceive but become pregnant at a later
estrual period, despite the obvious fact that the former group are
healthier than the latter.

The corpus luteum of pregnancy of the cow does not atrophy until
after calving and she is not usually in estrus until 20 to 40 days post¬
partum. Here, also, adequate data are wanting. My personal obser¬
vations indicate emphatically that the same principles apply as in the
mare and that early postpartum conception, before the reproductive
system has completed its involution and stabilization, is fraught with
increased danger of abortion. 1 have elsewhere pointed out20 that
when a cow conceives during a very early estrus after calving, there
is a well-defined tendency toward twin ovulation, with increased
danger of abortion.

ABORTION

(9) Starvation. Malnutrition. — When a large area suffers severely
from drought, when the grown crops are destroyed, or when adverse
weather causes widespread deterioration of the crops, and an ade¬
quate food supply cannot be imported, abortion becomes highly
prevalent. In the United States of America, probably the most illu¬
minating examples are to be found in the great grazing areas of the
Rocky Mountain region, where the rainfall is scant and erratic, with
now and then a long-continued drought. The cattlemen compute
the capacity of their range upon the basis of an average rainfall, and
when that drops far below normal, famine results and with it comes
pestilence. Abortion then becomes disastrous in beef cattle, which
as a rule suffer far less than dairy cows.

It has been experimentally shown, and is not disputed by clinical
observation, that when a food ration, ample in other respects, is
deficient in certain mineral constituents, or in vitamins, reproduction
is profoundly disturbed, with frequent abortions. In early veterinary
literature, great outbreaks of abortion in a country were referred to
food contaminated with secale cornutum. In modern times, experi¬
ments indicate that ergot possesses very limited, if any, power to
cause a domestic animal to abort. Their forage is usually polluted
in some measure by ergot or similar fungi. However, ergot is most
abundant in seasons of adverse weather associated with general de¬
terioration of food and an inevitable lowering of the inherent power
of resistance in the pregnant animal. Therefore, while dismissing
secale cornutum as an important direct cause of abortion, its influence
as an abortifacient must be accepted.

The Immediate or Exciting Causes of Abortion

In 1924, Williams, Udall, Frost, et al. 23 after an extensive study of
clinical material, held that abortion in cattle and horses, except when
precipitated by the removal of the corpus luteum, is uniformly asso¬
ciated with important utero-fetal lesions. It is not known, nor be¬
lieved, that any one of the above discussed factors, alone or in combi¬
nation, can produce any of the lesions described. From the clinical
viewpoint the lesions need be ascribed to the destructive action of
bacteria, protozoa or filter-passers. This conclusion, however, does
not detract in the least from the importance of the factors above
described as the basic causes of abortion. They so undermine the
strength of the animal and lower its intrinsic resistance, that patho¬
genic organisms, some type of which seem omnipresent, may destruc¬
tively attack the reproductive system.

ABORTION IN ANIMALS

Until within recent years, much stress was laid upon accidental
abortion, involving an endless catalog of mechanical injuries, strains,
falls, fright, etc. These are rarely mentioned now in veterinary liter¬
ature. In the studies of "W illiams et al ., cited above, no lesions were
found which might by any stretch of the imagination, be credited to

Fig-. 8. — Fetal cotyledons from healthy and diseased cows. 1, A typically healthy
cotyledon with closely packed, very fine chorionic tufts or villi, indicating- that the
corresponding- uterine caruncle was ideally healthy ; 2, dwarfed cotyledon from a
diseased cow. Almost all the villi have been destroyed by necrosis. A few coarse
tufts remain at a, while at b the necrosis is complete ; 3, a gig-antic cotyledon from
the same cow as 2, showing- very coarse clumpy tufts with extensive naked areas.
The uterine caruncle had suffered epithelial damage in a prior gestation, rendering
healthy placentation, as in 1, impossible. (Cornell Veterinarian, XIX, 1929.)

physical injury, nor has any veterinary writer, so far as known, de¬
scribed an abortion associated with lesions attributable to physical
injury. It is not to be inferred, however, that these accidents do not

ABORTION

lower the intrinsic resistance of the animal and enable other forces to
destroy the life of the fetns and cause the expulsion of the cadaver.

The lesions associated with abortion are of infinite variety, largely
referable to chronic inflammatory processes. The adeciduous pla¬
centae of domestic lierbivora afford a highly favorable opportunity
for accurate clinical study. Not only does the placental surface of
the chorion, unmasked by decidua, reveal clearly all lesions of that
structure but provides a detailed replica of the lesions of the endo¬
metrium. The uterus of the cow contains about 140 caruncles or spe¬
cialized placental areas already permanently fixed in the very small
embryo. Each caruncle, with its cotyledonous growths of gestation,
forms a separate field for detailed study. There occur necroses of the
cotyledons, which in succeeding pregnancies cause the placental tufts
of the chorion to be coarse and clumpy (Figs. 8 and 9). Sometimes

Fig: 9 —Magnified villi from 1 (left) and S, of preceding figure. (Cornell Veterinarian,

s XIX, 1929.)

calcification of the placental tissue occurs; in other instances the
entire caruncle undergoes necrosis and sloughs away at the base of
its pedicle, leaving behind, when it heals, a permanent cicatrix.

The inter-caruncular endometrium is frequently covered with an
extremely adhesive, yellowish or brownish exudate (the exudate of
contagious abortion) largely massed about the caruncular pedicles.
Areas of calcification are common. Associated usually with the necrotic
destruction of the caruncles, the inter-caruncular endometrium fie-
quently shows frail adventitious placental new formations which serve
in a measure as substitutes for the specialized areas upon the sum¬
mits of the caruncles.

The chorion is frequently edematous, indurated or calcified. In
cattle and sheep the abort usually suffers from fetal diarrhea prior
to its death and expulsion. Fetal diarrhea is extremely common in
pregnant dairy cows discarded for slaughter. The diarrhea runs ap-

ABORTION IN ANIMALS

proximately parallel with the extent of the utero-chorionic lesions,
and appears at any time after mid-term. Occasionally calves are horn,
thickly smeared over with diarrheic meconium. Such calves are
rarely viable.

Here arise two antagonistic hypotheses. One group contends that
the bacteria most frequently associated with abortion, such as Bacillus
abortus, possess such exalted powers of invasion that they readily over¬
leap any barrier which a healthy animal may erect, and cause danger¬
ous contagious diseases demanding for their control, artificial im¬
munization, quarantine or slaughter of the affected animals. The
other group believes that abortion in domestic animals is primarily
due to an abnormally low intrinsic power of resistance, caused by
one, or several of the basic factors already discussed, which serve to
open the way for destructive invasion by bacteria not ordinarily com¬
petent to induce abortion in a definitely healthy individual.

The first group, e.g. Fitch and Bishop8 insist that the healthy uterus
is essentially always bacteria-free, while the second group, e.g. Beller3
and Wagner17 contend that it may contain an infinite variety of or¬
ganisms, few in number and destitute of pathogenic power in a clini-
callv healthy animal.

The conflict is perhaps one of definition rather than of fact. Numer¬
ous clinicians regard a dairy cow as healthy when year after year she
conceives promptly, does not abort, calves at term and milks fault¬
lessly, but according to the first group, should the cow have in her
uterus at calving time a few Bang’s bacilli, she would be classed as
diseased. Some of the first believe that the findings of the second
group are due to faulty technic and in support of their contention
plead guilty to faulty technic themselves. When Fitch and Bishop
find swarms of B. abortus in an aborting cow their technic is above
question, but when they recover a few bacteria, without high repute
as abortion-producers, these are attributed to contaminations through
faulty technic. White, Johnson, Rettger and McAlpine18 record that
a certain Ayrshire cow in the Connecticut Experimental Station herd,
carrying abortion bacilli, bred ideally, calved physiologically and
stood first in the herd for milk production. Clinically she was the
healthiest cow in the herd while legally she was infected with a highly
dangerous contagious disease.

Reproduction is a luxus function and constitutes a burden beyond
the physical needs of the parent. From the union of two microscopic
cells there is hurriedly created a new individual, complete in organi¬
zation and ready to assume an independent existence at birth. The
fetal membranes, which constitute the contact system between the

ABORTION

fetus and mother, are very hastily constructed and are later abruptly
discarded at birth. The uterus grows in size and function at a phe¬
nomenal rate. Logically, the hastily developed placental and fetal
tissues should not be expected to be so resistant as old established
structures. The thought is well supported by the virtually universal
declaration of bacteriologists that the abortion bacillus regularly dis¬
appears from the uterus 2 to 3 weeks post-abortum, he., as soon as
uterine involution has been accomplished and the hastily formed new
tissues have been removed. Pursuant to this inference, the intra¬
uterine mortality in domestic mammals is many times as great, as din¬
ing any unit of time in postnatal life. The clinician observes that
when the vigor of a pregnant female is greatly lowered, through one
of the causes mentioned, or other similar agencies, evidences of the
invasion of the reproductive system by destructive organisms are
abundant, amongst which abortion constitutes the most spectacular
phenomenon. The list of organisms which have been found in as¬
sociation with abortion is endless. A few of them have been sub¬
jected to extensive study.

(a) Bacillus Abortus (Bang).— In 1897 Bruce discovered Micro¬
coccus melitensis in the blood of men suffering from Malta fever and
in the milk of goats being used by the men. In 1906 Bang2 discovered
Bacillus abortus in the uterine contents of an aborting cov . Latei the
supposedly different organisms were found to be essentially identical.

Far back in veterinary history the belief became firmly established
that cattle abortions were separable into two primary classes, con¬
tagious and accidental. It was taught that there was but one con¬
tagion, a highly virulent malady which defied all natural barriers and
raged as a pestilence like rinderpest or foot-and-mouth disease. The
belief became a deeply rooted tradition. When bacteriology became
established as a science, the quest for the bacterium of contagious
abortion became one of the great adventures in veterinary science.
Several investigators recovered various bacteria fiom the uteii of
aborting cows, but each failed to convince the veterinary profession
that the organism identified was the cause of the traditional pesti¬
lence. Finally Bang succeeded in culturing the bacillus which he had
found, injected the cultures into pregnant cows and some of them
aborted. He thereupon announced the discovery of THE bacterium
of contagious abortion and the conclusion was generally accepted.

Bacillus abortus occupies a unique position in veterinary medicine.
Next to Bacillus tuberculosis, if it does not surpass it, it is credited with
being the most widely disseminated bacterium associated with the
diseases of domestic animals, and is linked with the most varied

ABORTION IN ANIMALS

category of clinical phenomena of any pathogenic organism. Besides
being incriminated as the cause of most abortions in cattle, it is held
responsible, directly or indirectly, for the vast losses from retained
placenta and sterility, is charged with being the cause of carpal
hygroma in stanchioned cattle, of fistulons withers in horses, and of
nndnlant fever in man, and is much in evidence in association with
abortion in goats, sheep and swine. Under the natural mode of trans¬
mission of B. abortus infection, it is extremely rare to observe clinical
manifestations of bacteremia in cattle or other domestic animals.
Experimentally, when large doses of highly virulent cultures are in¬
jected hypodermically into susceptible dairy heifers, there frequently
follow extensive abscesses at the point of injection, associated with
prolonged malaise and marked loss of weight (undulant fever?), but
no accurate studies of the phenomena have been recorded.

Many other bacteria and protozoa have been recovered from the
uterine contents of aborting cows. In other instances there are clini¬
cal evidences of the presence of a filterable virus. The suspected or¬
ganisms have been used to expose other pregnant cattle, some of
which have aborted, and the organism recovered from the uterine
contents. This should be expected if the exposure is equal and the
intrinsic power of resistance parallel. A very large proportion of
abortions in cattle are bacteria-free according to accepted standards
of diagnosis. In cases of abortion, attributed to Bang’s bacillus, in
those in which other bacteria are found in the absence of Bang’s bacil¬
lus, and in those very numerous cases in which no bacteria, or pro¬
tozoa are found, and in which no clinical evidences of disease due to
filter-passers are present, always we find the same symptoms.

Some authorities contend that the lesions in abortions where />.
abortus is present, differ somewhat from those observed where that
bacillus is absent and other bacteria are present, or the examination
for organisms is negative. Other authorities of equal standing, e.g.
Beller3 are quite as certain that no such differences exist. Those abor¬
tions in which B. abortus is present, however, are classed as due to a
specific disease, those in which other bacteria appear, as non-specific,
and those which are negative to bacteriologic search, to unknown
causes.

In the United States of America most states have established rules
barring the importation of breeding cattle unless they are officially
certified by the exporting state as free of infectious abortion. No
quarantine is established to bar the introduction of men, horses, goats,
sheep, swine or other carriers of Bang’s bacillus. The diagnosis for
purposes of interstate shipment is commonly based upon the aggluti-

ABORTION

nation test, but no universal titre lias been adopted. Some authorities
advocate 1:20, others 1:200, with numerous intervening standards.
A newborn, vigorous calf is usually negative at 1 :10.

Numerous experiments have been recorded in which pregnant
heifers have been variously exposed, have largely aborted, and B.
abortus have been recovered. Other experimental exposures, in which
abortion failed to follow, have not received great publicity. As a rule,
though not prominently mentioned, the experiments are conducted upon
dairy heifers which largely abort whether artificially exposed to
Bang's bacillus or not and in many cases no bacteria are recoverable
from the abort. For example, Cotton, Buck and Smith5 in an experi¬
ment, selected 8 heifers as controls, 6 of which proved sterile. In their
places 6 other heifers of inferentially parallel sexual health were sub¬
stituted. Each received 3 drops of abortion culture in the conjuncti¬
val sac and all 8 aborted. Clinical observation reliably teaches that
in a fairly uniform group of dairy heifers, 75 per cent of which are
sterile, the 25 per cent which conceive may be confidently expected to
abort at a ratio of at least 75 per cent, and no surprise should be
caused by 100 per cent of abortion without artificial exposure.

When experimenters select animals for abortion exposure, the fac¬
tors discussed above as basic causes of abortion are not considered.
Among the great number of experiments designed to establish the
abortifacient power of Bang’s bacillus, no record is found of an in¬
stance in which healthy beef heifers of mature age have been selected.
It is not known what would occur if a group of healthy beef heifers,
grown naturally upon the open range with ample forage, and mated
with healthy bulls at a time to first calve at three years of age, were
exposed to contagious abortion by placing three drops of a culture
into the conjunctival sac. There are ample clinical reasons for the
suspicion that the exposure would be without visible effect.

(b) Spirilla or Vibrios Associated with Abortion. — A spirillum or
vibrio is occasionally found in abortions of cattle in which Bang’s
bacillus is not recognizable. Barely the vibrio and Bang’s bacillus
are both present. The symptoms and lesions differ in no known re¬
spect from those associated with B. abortus. A similar organism is
frequently found in association with ovine abortion.

(c) Bovine Abortion Associated with the Vesicular Venereal Dis¬
ease or Coital Exanthem. — Reisinger14 has described a very extensive
and destructive outbreak of abortion and sterility of cattle in South¬
ern Austria in which he presents highly interesting clinical, and some
experimental, evidence that it was due to the vesicular venereal dis¬
ease, presumably, like most vesicular diseases, referable to a filter-

ABORTION IN ANIMALS

passer. A similar disease appears in horses. They are extremely
contagious. In my observation 100 per cent of exposures terminate
in disease. The disease is interesting, clinically, in that it appears in
a manner possibly best expressed as “spontaneous” in so far as clini¬
cal observations lead. Usually it suddenly appears without known
introduction from without, and before the caretakers have noted its
presence, each female served by the affected male shows a notable
abundance of vesicles about the vulva, the male showing correspond¬
ing lesions of the penis. In harmony with suggestions previously
made, the inference is allowable that the causative virus may be
widely disseminated but in so avirulent a state that it does not pro¬
duce clinically recognizable disease until some depressing factor (ex¬
cessive coitus by the male ?) serves suddenly to awaken the virus.
Then it develops into the most spectacular venereal disease of domes¬
tic animals. The power of this disease to cause abortion is not com¬
pletely established. In Reisinger’s observations the most prominent
phenomenon Avas maceration of the fetus with chronic pyometra. In
some cases, however, the fetal cadaver was expelled promptly follow¬
ing death. The death and maceration of the fetus, and extensive pyo¬
metra are also described as characteristic of the trichomonas disease,
to be discussed below. The differentiation between the two is not clear.

(d) The Trichomonas Disease. — Since 1900 there have appeared oc¬
casional reports of abortion, maceration of the fetus and extensive
pyometra in which trichomonas were obtained from the uterine con¬
tents, in the absence of abortion bacilli or other organisms readily
incriminated. Abelein1 presented an extensive report in 1932, with
bibliography, which may be cited as representative. Until 1932 re¬
ports came only from Continental Europe. Recently the disease has
been reported in several areas of the United States of America and a wide
dissemination seems to exist. Probabty the disease has existed in this
country for a long time unrecognized. As early as 1929 Lotlie11 de¬
scribed an outbreak of abortion in Wisconsin with a clinical picture
of trichomonas disease, but the underlying cause was undetermined.

(e) Miscellaneous Infections Associated with Abortion. Abortions
Without Recognizable Infections. — An endless list of bacteria and
other organisms are occasionally found in association with abortion
in cattle and other animals. They ordinarily are apparent in but
few cases in a given area. They include various pyogenic types.
Somewhat rarely the bacillus and lesions of bovine and avian tuber¬
culosis are found in cattle abortions. In one instance I observed
uterine actinomycosis.

ABORTION

In all countries there are many abortions in both horses and cattle
not yet attributable to any form of bacteria, protozoa, or filter-
passer. The lesions present cannot be attributed to physical vio¬
lence, Secale cornutum, or other traditional factors. The lesions indi¬
cate the presence of infection, but they differ faintly, if at all, fiom
those assigned to B. abortus. One of the unsolved enigmas m abortion
in domestic animals is the vast number, often reaching 50 per cent of
the total in a considerable territory, in which no biologic cause can
be discovered, yet the lesions impress the clinician as bacterial. These
negative cases serve to obscure the diagnosis, where an abundance of
bacteria are present which have an established reputation as abortion-
producers, because no means are available by which, in the presence
of such bacteria, the unknown cause may be excluded. Under c the pos¬
sibility, or even probability, of the filtrable virus of the vesicular vene¬
real disease to produce abortion has been discussed. It is not impossible
that this virus may cause abortion without the visible presence of the
vesicular eruptions. Dimock6 confronted with disastrous outbreaks of
equine abortion in connection with which no bacteria with an aborti-
facient power could be recognized, and in which no bacteria were found,
resorts to the hypothesis of a filter-passer as the cause. He produces in¬
teresting evidence in support of his suspicion. Should the suspicion
prove correct, Dimock would face the problem, when Salmonella abor-
tivo-equinus is present, of determining if the abortion were due to the
bacillus or the filter-passer.

(f) Dourine. — There occurs in horses the highly destructive vene¬
real disease known as dourine, due to Trypanosomum equiperdum.
Influential writers state that it causes abortion. In a large outbreak of
the disease, the first reported in North America, the control of which
fell to my lot, no case of abortion was observed, nor do I recall the
existence of pregnancy in an affected mare. The available statements
regarding abortion in dourine are apparently based upon categorical
assertion alone. According to my observations it appears that fertili¬
zation fails or the fertilized ovum perishes before pregnancy is recog¬
nizable.

(g) Bacterium Paratyphus Abortus Equi. (Salmonella Abortivo-
Equinus.)— Paratyphoid bacteria are frequently found associated
with abortion in all herbivorous domestic animals. It is commonly
assumed that a separate species or variety of bacterium occurs in each
species of animal. In other animals than the mare this type of organism
is not regarded by American veterinary writers as causing a ‘ ‘ dangerous
contagious disease,” calling for quarantine or slaughter of the abort¬
ing females. In equine abortion the paratyphoid bacillus is by far

ABORTION" IN ANIMALS

the most frequently recognized bacterium, comprising, according to
the extensive data of Liitje,12 41.7 per cent of all abortions, or de¬
ducting 48.3 per cent of the equine abortions investigated, which were
negative to bacterial search, Liitje found the paratyphoid organism
in over 80 per cent of all bacteria-positive examinations. The para¬
typhoid bacterium has been accorded a place in equine abortion analo¬
gous to that occupied by Bang’s bacillus in bovine abortion. It is
regarded by many as a highly dangerous contagious disease, but no
official regulations of quarantine or slaughter have been enacted.

The symptoms and lesions of paratyphoid abortions in mares are
not known to differ specifically from those equine abortions attributed
to any one of numerous other bacteria, nor do they differ, so far as
known, from those of the 48.3 per cent of the total in which the bac-
teriologic search is negative.

The Control of Abortion in Domestic Animals

It has already been stated that there exist two antagonistic views
of the causes of abortion in domestic animals. One is that abortions
are fundamentally due, at least in most cases, to the invasion by con¬
tagions so virulent that they ignore any and all intrinsic powers of
resistance to disease. The other belief is that abortion is primarily
due to a subnormal power of resistance in the individual, caused by
malnutrition, excessive sexual load or other depressing agencies which
invite destructive action by organisms otherwise devoid of material
pathogenic power.

This conflict of view leads inevitably to two irreconcilable concep¬
tions of the principles of control. Since the discovery of B. abortus
the control of cattle abortion, as advocated by the first group men¬
tioned, has been centered upon the one organism. While many bovine
abortions are admittedly not due to Bang’s bacillus, they are dis¬
missed as immaterial or because the cause is unknown and hence
beyond remedy. In the original communication of Bang2 it was con¬
fidently predicted that abortion would be controlled either by arti¬
ficial immunization or by quarantine. It has not yet been clearly
established that a chronic infectious disease, which is chronic largely
because it does not itself produce immunity, can be effectively con¬
trolled by artificial immunization. Many highly favorable reports
are published advocating the use of the living bacilli as an immuniz¬
ing agent. The experimental evidence is not without important de¬
fects. The clinician who applies the method in privately owned herds
generally observes silence unless the apparent benefits are spectacu¬
lar. Reports are not available from publicly owned herds observed

ABORTION

over a series of years, and the incidence of sterility, retained placenta
and other allied phenomena is not stated. In the extensive experi¬
ments of Bland4 the abortion rate was materially reduced and coun¬
terbalanced by an increase in sterility. It must be admitted that
artificial immunization cannot transform such grossly hypoplastic
genital organs as I have described22 into a physiologic reproductive
system, nor abrogate any one of the basic causes of abortion above
discussed.

Quarantine was already in vogue prior to the dawn of bacteriology
as a science. The elimination of Bang-positive cattle from a herd can¬
not prevent the re-introduction of the bacillus by men, horses, goats,
sheep, swine and other animals known to be carriers. A serious
economic problem in quarantine is vividly presented by Hicks.9 In
the Dominion Experimental Farm at Agassiz, B. C., the mature cows
in the herd in 1927 were almost all Bang-positive and were breeding
and milking excellently. The heifers and young cows were virtually
all Bang-negative, and sterility and abortion were highly prevalent.
All animals were in immediate contact and the sterile and aborting
heifers obstinately refused to become affected with contagious abor¬
tion. The elimination of the Bang-positives would remove most of the
highly fertile cows and leave in the herd the sterile heifers and abort-
ers. I have elsewhere described a free-martin,20 from a highly fashion¬
able, Bang-negative herd in which the abortion rate, from unknown
cause, was 50 per cent. Since the cause was unknown, there was no
remedy. A second free-martm mentioned in the same article came
from a dairy herd of satisfactory fertility until it was desired to
introduce a new bull from a famous herd in another state. He was
admitted upon an official certificate of freedom from contagious abor¬
tion. Some of his cows failed to conceive and other bulls were sub¬
stituted. After several bulls and numerous cows had been irretriev¬
ably ruined, it was observed that the clinical picture in the herd was
suggestive of that drawn by Abelein1 in connection with trichomonas
disease, and a search quickly revealed the presence of the protozoon.
The third free-martin in the article cited came from a Bang-free herd
in which the fertility was high. In addition to the isolation of Bang¬
positive animals, the attending veterinarian had largely applied meas¬
ures aimed to obviate what have been described above as the basic
causes of abortion. Opinions will naturally differ regarding the cause
of the fertility, whether it was due to quarantine, or to sex hygiene.

In contrast I have elsewhere recorded22 extensive observations in a
large Holstein herd, destructively affected with abortion and other
genital diseases. The period covered was 14 years and the herd in-

ABORTION- IN ANIMALS

creased from 60 animals to over 300. It was separated only by a wire
fence from thousands of Hereford cows of high fertility. The meas¬
ures adopted for control were directed toward the elimination of
those agencies described above as the basic causes of abortion, with¬
out artificial immunization or quarantine. The chief emphasis was
laid upon the correction of malnutrition of the young calves, thereby
controlling the gross hypoplasia of the reproductive system. The
results proved highly satisfactory. These and other observations
justify the conclusion that abortion in domestic animals is best con¬
trolled by the rigid application of the laws of hygiene, including espe¬
cially the avoidance of malnutrition from the beginning to the end
of life, and the conservative adjustment of the burden of reproduc¬
tion to the strength of the individual.

Abortion leaves behind important lesions of the endometrium, which
heal by cicatrization, not by renewal of the destroyed tissues. The
available placental area is decreased and the cicatrized portion is
weakened. Many aborters die, especially cows with retained placenta ;
many more become permanently sterile. Numerous animals that have
aborted, so far recover that they breed well. Animals that abort
early in gestation, and expel the ovum intact within its membranes,
usually make a fair recovery, while those that abort late and retain
the placenta (cow), commonly breed poorly or not at all. The dam¬
aged bovine uterus has two methods of compensation for destroyed
placental tissues, the hypertrophy of intact caruncles and the for¬
mation of adventitious placental structures in the intercaruncular
endometrium. They aid materially in the nutrition of the ovum but
inevitably fall below the natural organs in their efficiency.

Abortion in Captive Wild Animals

Nothing is found recorded regarding abortion in wild animals un¬
der normal environment. Reproduction in captive wild animals is
low. Fox8~a states that abortion is occasionally observed in zoological
parks in monkeys, rodents and ungulates, and attributes it to an¬
noyances by other animals, immaturity of the pregnant female and
osteomalacia.

Noback13'a has observed abortions in marmosets and attributes the
disease to malnutrition, associated with rickets.

Hartman and Tinklepaugh8'b state that intrauterine mortality in
rhesus monkeys reaches, in their research colony, 30 per cent, without
including those abortions occurring just after the pregnant animals
have arrived from the dealer. They attribute the abortions to funda-

ABORTION

mentally defective ova or to general ill health of the mother. A con¬
siderable number of the aborting females were of subnormal weight.

Professor Yerkes25 has observed 30 per cent of miscarriage in a
colony of Chimpanzees and concludes that the primary determinants
of the outcome of gestation are the general health of the animals and
the character of the diet.

None of the observers have seen indications of accident or con¬
tagion as a fundamental cause of abortion.

References

1. Abelein, R. : Die Trichomonadenseuche des Rindes und das Scheidenkatarrhprob-

lem. 1 Miinchen. Tierarztlichen Wchnsclir. 83 Jahr. 1932. _ _

2. Bang, B.: Die Aetiologie des seuclienhaften Yerwerfens. Ztschr. f. Tiermediem

1: 241, 1897.

3 Beller Karl: Anatomische, physiologische und bakteriologische Untersucliungen
der Trachtigkeit und Geburt bei Haustiere. Deutsche tierarztliche Wchnsclir.

33: Nos. 14-15, 1925. _

4. Bland: Reports Agr. Organizer, Oxford County Council Education Committee,

1911-1916. „ ^ .

5. Cotton, W. E.. Buck, J. M., Smith, H. E. : Studies of Five Brucella Abortus

Strains as Immunizing Agents Against Bang’s Disease. J. Am. Vet. Med.

Assn, lxxxv, 232, 1934. „ ,

Dimock, W. W. : Infections of Fetuses and Foals. Bull. boo. Ky. Agr. Bxpt.

Sta., 1932. . „ ^ n

Errington, J. B., and Williams, W. L. : The Placentation of Equine Twins. Cor¬
nell Veterinarian 23: 354, 1933.

Fitch, C. P., and Bishop, L. M.: A Bacteriological Study of the Gravid and
Nongravid Uterus, Cornell Veterinarian 22: 225, July, 1932.

. Fox, Herbert, M.D.: Diseases of Captive Wild Animals, 1923, J. B. Lippincott

8b. Hartman, Carl G., and Tinklepaugh, O. P. : Weitere Beobachtungen iiber die
Geburt beim Affen, Macaous rhesus , Arch. f. Gynak. 149: 21, 1932;

9. Hicks, W. H.: Report Superintendent Experimental Farm. Agassiz, British

Columbia, 1927.

10. Lagerlof, Nils: Morphologisclie Untersucliungen ueber Veranderungen nn

Spermabild und in den IToden bei Bullen mit verminderter oder aufgehobener
Fertilitat. Acta Patliologica et Microbiologica Scandinavica. Supplementum
xix. Upsala, 1934.

11. Lothe, H.: The Breeding Efficiency of a Herd of Cows Negative to the Agglu¬

tination Test, J. Am. Vet. Med. Assn. 75: 143, 1929.

12. Liitje, Fr.: Abortus. Stang-Wirth, Tierheilkunde und Tierzucht 1: 21, 19ffi.

13. McCampbell, C. W.: Beef Cattle Experiments, Fort Hays Branch, Kansas Ex¬

periment Station, 1919-1920.

13a. Noback, E. V.: Veterinarian New York Zoological Park.

14. Reisinger, L. : Untersucliungen iiber ein in Oesterreich gehauft auftretendes,

jedoch nicht durcli den Bang’schen Bacillus verursachtes Verwerfen der
Rinder, Wien, tierarztliche Monatschr. 15: 49, 1928.

15. Savage, A., and Williams, W. W.: A Statistical Study of the Head Length

Variability of Bovine Spermatozoa and Its Application to the Determination
of Fertility. Transactions Royal Society of Canada, 1927,. p. 425.

16. von Oettingen, Burchard: Die Pferdesucht. Paul Parey, Berlin, 1921.

17. Wagner, H. : Untersuchen fiber Gebarmutter-und Jungtierkranldieiten, Deutsche

tierarztliche Wchnsclir. 35: 655, 1927. (Translation. Cornell Veterinarian 18:

.225, 1928.) . t~,

18. White, G. C., Johnson, R. E., Rettger, L-. F., and M ’Alpine, J. G.: Some Eco¬
nomic Phases of Bacterium abortus Infection and Other Observations m
Dairy Herds. Bull. 135, Agr. Expt. Sta. Storrs, Conn., 1925.

ABORTION IN ANIMALS

19. Williams, W. L. : Veterinary Obstetrics. 2nd Ed. 1931, p. 355.

20. Williams, W. L. : A Clinical Study of Bovine Twins and Free-Martins, Cornell

Veterinarian 24: 109, 1934.

21. Williams, W. L. : The Male as a Spreader of Genital Disease, Cornell Veteri¬

narian 13: 108, 1923.

22. Williams, W. L. : The Influence of Ante-natal and Early Post-natal Health of

Calves upon Their Vigor and Fertility as Adults, Veterinary Record (Lon¬
don) 15: 49, 1935.

23. Williams, W. L., Udall, D. H., Frost, J. N., Goldberg, S. A., et al.: Studies in

Genital Disease, Cornell Veterinarian 14: 315, Oct., 1924.

24. Williams, W. W., and Savage, A. : Observations on the Seminal Micropathology

of Bulls, Cornell Veterinarian 15: 353, 1925.

25. Yerkes, Prof. Robert M. : Personal communication.

CHAPTER IV

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

I N ORDER properly to appreciate the underlying factors in the
* etiology, pathology and treatment of abortion, it is well to review
briefly the anatomical and physiological changes that occur during
the first six months of pregnancy. We shall confine ourselves in the
main to those facts that bear directly or indirectly upon clinical
aspects of abortion.

The process of implantation is one of gradual change and adjust¬
ment during which certain characteristics develop in the relation of
the ovum to its host that permit the division of the pregnancy into
three anatomical stages :

One, the decidual stage : first six weeks.

Two, the attachment stage: seventh through the twelfth week.

Three , the placental stage: thirteenth week to termination of preg¬
nancy.

(1) The Decidual Stage

(First Six Weeks from Fertilization)

Fertilization. — The human ovum is usually fertilized in or near the
fimbriated end of the tube. As it pursues its course downward through
the tube, the impregnated ovum passes through the early stages of
cell division. Its progress is somewhat slower as it approaches the
uterus, and it reaches the cavity within approximately a week. Dur¬
ing this time the ovum has progressed to a cleavage cluster not much
larger than the single cell, though greatly subdivided, and still sur¬
rounded by the zona pellucida. In three days more, or in about ten
days from fertilization, the ovum is ready for implantation.

The stages from eruption of the ovum from the ovary, through
fertilization, early cleavage, and travel along tube and in the uterine
cavity, through implantation in the mucosa, are shown in Fig. 10.
This diagram by Dickinson was adapted from the chart of the great
teacher, Sellheim, and has been brought up to date by careful check¬
ing with the latest discoveries and observations recorded by Streeter
and Hartman in the Department of Embryology of the Carnegie Insti¬
tution at Johns Hopkins.

Implantation. — The uterine mucosa has undergone marked changes
during this week that the ovum has been traveling through the tube.
Its thickness has increased three or four times, the glands have taken

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

on a markedly convoluted character; and the connective tissue cells
already have begun to assume the characteristics of decidual cells. In

Fig. 10. — Passage of impregnated ovum through the Fallopian tube and implantation

in the uterus.

gross appearance the uterine mucosa has multiple folds, upon whose
top or sides the ovum is usually implanted.

ABORTION

Site.- — We know but little as yet concerning’ the factors that pre¬
dispose to a particular site for implantation. Dickinson has made a
careful study of the sites of the ovum in 56 very early pregnancies,
and in nine-tenths of these the point of implantation was in the mid¬
line on either the front or rear wall of the uterine cavity. In only
three instances was the implantation in the fundus, and twice it was
near the tubal openings (see Fig. 11). At this stage the ovum will
be recognized with the greatest difficulty in the gross specimen. It
will appear as a minute vesicle upon the top or side of a mucous fold
with slight injection of the surrounding blood vessels (Fig. 12).

Trophoblast.— Presumably implantation is accomplished through
the presence of enzymes in the external trophoblast cells of the ovum
by which the maternal tissues in contact with them are digested, the

endometrium is opened and the trophoblast permitted to grow into
the mucosa. The point of penetration in the mucosa is usually micro¬
scopic and after the ovum has become entirely imbedded, a small cap
of fibrinous blood clot marks the point of entry. The local irritation
produced by the trophoblast greatly increases the size of the capil¬
laries in this region and by a process of liquefaction necrosis, the
trophoblast now opens into these capillaries so that numerous small
lacunae of maternal blood surround the growing embryo. These
spaces are filled with an emulsion of blood and cellular debris known
as embrvotroph which serves as food for the embryo until the nutri¬
tive mechanism is more fully developed through the formation of the
embryonal blood vessels. The process of implantation probably takes
not over twenty-four hours.

°vum

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

Three very early pregnant uteri (Stoeckel, Leopold, Peters.) (Redrawn by Dickinson.

ABORTION

Syncytium. — The first development of trophoblast epithelium is in
the form of a web-like growth known as syncytium as seen in the twelve
to fourteen day ova of Miller and Yon Moellendorf (Fig. 13). In the

Body Stalk

Amnion ^olksac

Trophoblastic Lacuna

Fig. 13. — Human embryo of about ten days’ fertilization age. Photomicrograph
of a section of the Miller embryo. Gy. Tr., Cytotrophoblast ; Ex. Coel., extra-em¬
bryonic celom ; Ex. Mes., extra-embryonic mesoderm ; PI. Tr., plasmodiotrophoblast ;
Sh.f space between extra-embryonic mesoderm and trophoblast due to shrinkage in
fixation. (After Streeter, from Arey in Curtis: Obstetrics and Gynecology, courtesy
of W. B. Saunders C'o.)

famous Peters ovum (15 to 17 days old), a second trophoblast pro¬
liferation of large ceils has occurred with the development of trabecu-

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

lae that represent the primary chorionic villi. Additional areas of
maternal tissue surrounding the ovum are now attacked and larger
pools of maternal blood are opened up. In the Mateer ovum of 19
days there is already evidence of the down-growth of mesodermal
tissue into the primary chorionic villi with a differentiation of tropho¬
blast into an outer syncytial and an inner Langhans layer. In the
embryo of three weeks, minute capillaries seen in these chorionic villi
give evidence of the formation of a fetal circulation. Blood vessels
pass from the embryo through the body stalk into the villous stems
(Fig. 14).

Embryo. — While these changes are occurring in the trophoblast
area, the embryo itself first progresses from a disc to the stage of
primitive streak with formation of the mesodermal somites. The yolk

Canalized fibrin Maternal capillary Intervillous space

Cytotroph obi a st —

Plasmotrophoblast {

A nchoring villus
Endothelium

Wall of chorion

Core of villus

Fig-. 14. — Diagram of the early development of chorionic villi and placenta. (After
Peters, from Arey : Developmental Anatomy, courtesy of W. B. Saunders Co.)

sac which plays such a prominent part in lower animals, has become
reduced in size and forms a small vesicle lined with a single layer of
entoderm and surrounded by mesoderm. The amniotic cavity, notice-
able as a small flat sac in embryos from 13 to 14 days, quickly en¬
larges in the following week with the development of fluid in which
the embryo floats, attached to its trophoblast by a short thick stalk
that later becomes the umbilical cord. The 4 to 6 week emhryo is
characterized by a relatively large over-arching head, with protrud¬
ing eyes, gill slits, a thick bulbous neck, protuberant abdomen, and
short stump-like extremities (Fig. 15).

Decidua. — Of special interest and importance is the development of
the maternal mucosa into decidual layers (Fig. 16). That portion of

ABORTION

the uterine mucosa which covers the ovum, is subjected to consider¬
able stretching by the growth of the ovum so that the decidua that
develops in this area is attenuated and the uterine glands in this en¬
capsulating mucous membrane are flattened out and tend to run

Mandibular
Arab

Maxil

rocess

Eye -

Nasal Pit

Cardiac
Prominence

Hepatic
Prominence

Belly

Stalk

Leg Bud

Cervical

Si nus

Hyoid
Arch

Arm

Bud

Mesonephric

Prominence

Fig-. 15.— Human embryo of about five weeks’ fertilization age. Sketch, lower
right, shows actual size of embryo and its chorionic vesicle. (Patten and Hartman
in Curtis : Obstetrics and Gynecology , courtesy of W. B. Saunders Co.)

parallel with the circumference of the ovum. We speak of this por¬
tion of the embryonal covering as the decidua capsularis. Beneath the
point where the ovum is implanted, the decidual reaction is most pro¬
nounced ( decidua basalis) . This area can be divided into a thicker

ANATOMY AND PHYSIOLOGY OP EARLY PREGNANCY

compact layer ( decidua compact a) directly in contact with the tropho-
blast of the embryo, and a deeper situated layer containing numerous
tortuous glands ( decidua spongiosa) . This decidua basalis is differen-

Allantois

Umbilical cord with its
contained vessels

Placental villi imbedded in the

. Decidua basalis

' Uterine tube

N on-placental villi imbedded in
the decidua capsularis

Cavity of uterus
Yolk-sac

Cavity of amnion

-Decidua vcra or
parietalis

Plug of mucus in the
cervix uteri

Fig. 16. — Sectional plan of the gravid uterus at three months. (After Wagner,
from Arey: Developmental Anatomy, courtesy of W. B. Saunders Co.)

Ei mit Dec.
rellexa iiber-
zogen

Decidua JEera

Fig. 17. — Ovum in situ of about four weeks’ development, showing the formation of
the decidua vera, with the rellexa covering the ovum. (Bumm. )

tiated from the remaining uterine mucosa filled with decidua cells to
which the term decidua parietalis (formerly decidua vera) is applied.

ABORTION

The pregnant uterus with embryo, shown in Fig. 17, demonstrates the
anatomic conditions near the conclusion of the first six weeks of
gestation.

(2) The Attachment Stage

(Seventh to Twelfth Week)

The second six weeks of fetal development are characterized by the
gradual formation of the placental site and the more firm attachment
of the ovum to the uterine wall. It is not until the conclusion of this

Z months prec/ncuit icterus
Normal position

Fig-. 18 -A. — Two months pregnant uterus in normal position in pelvis.

period, at the end of the twelfth week, that a relatively firm attach¬
ment has been effected and it is therefore evident that up to this point
the detachment of the ovum may more readily be brought about. The
more important steps in the development of this process of uterine at¬
tachment consist in the prolongation through the basilar decidua of
large villous stems. At first the chorionic villi cover the entire surface
of the chorion evenly but at the seventh week they are definitely
shorter and fewer over the capsule of the ovum. At the base of the
ovum these villi represent bush-like tufts with but few branches, and
between them the maternal blood vessels form larger spaces (inter-

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

villous spaces) through which the maternal blood slowly circulates,
bringing nourishment to the ovum and carrying from it certain waste
products. Week by week this basilar region becomes thicker and
more deeply invades the maternal tissues. At the same time the
growth of the embryo and the increase in the amniotic fluid gradually
produces complete occlusion of the remaining uterine cavity (Fig. 18)

Fig'. 18-B. — Eight weeks pregnant uterus, showing incomplete obliteration of the
uterine cavity. (Specimen from Washington University Department of Obstet¬
rics. )

so that at the end of twelve weeks the capsular decidua lies in con¬
tact with the parietal decidua with which it then becomes fused.

Changes occur in the size and shape of the embryo in the six weeks
of the attachment stage. The body assumes a less bent attitude, the
head is relatively large with a shorter, better defined neck. Thorax
and abdomen are differentiated, fingers and toes are visible upon the
jointed extremities, and the external genitals show beginning sexual
differentiation.

ABORTION

(3) Placental Stage

(Thirteenth Week to Termination of Pregnancy)

After the twelfth week of gestation the mass of tissue at the base
of the fetal attachment forms a thick round pancake and can now
properly be termed placenta. The remainder of the uterine cavity is
lined by parietal decidua, capsular decidua and chorio-amnion. These
fuse into a layer which with the growth of the fetus becomes greatly
thinned and is known as the membranes. Prom the twelfth week on¬
ward the parietal decidua through increasing pressure is so reduced
in size that it can only be recognized microscopically. At the end of
the twelfth week the placenta occupies only about one-third the sur¬
face of the uterine cavity, whereas at the twentieth week it extends
over one-half of this surface. At this time its diameter is 12 to 13
centimeters and its thickness about 2 centimeters (Pig. 19).

Usually fairly near the center of the placental cake is the attach¬
ment of the umbilical cord, through the vessels of which the fetus
gets its nourishment. The capillaries of this fetal blood system enter
into the chorionic villi to which the term chorion frondosum, or bushy
chorion, is applied in differentiation from the chorion laeve , or smooth
chorion, situated in the membranous wall. Of some interest is the
separation of the chorionic villi of the placenta with their surround¬
ing masses of maternal decidua into definite lobes. This lobulated
appearance of the placenta comes about through the development of
larger septa, after the fourth month, presumably due to the faster
rate of horizontal growth of the uterine wall in comparison to the
placenta. This results in the production of decidual folds between
the rapidly enlarging villous trees with the formation of cotyledons.
Each cotyledon lias a main villous stem with separate blood vessels.

Age and Length. Details of the development of the fetus during
these months can be found in textbooks on embryology. For identify¬
ing the age of an abortion fetus the old formula should be remem¬
bered according to which the length of the fetus is equal in centi¬
meters to the square of the number of months for the first five lunar
months and that five centimeters are added for each lunar month
thereafter :

Lunar month

cms.

Lunar month

cms.

1st

6th

2nd

7th

3rd

8th

4th

9th

5th

10th

ANATOMY AND PHYSIOLOGY OF EARLY PREGNANCY

With the growth of the fetus the relative size of the head becomes
less marked. The soft lanugo hairs are found upon the skin ; the sex
of the child is readily determined after the third month by inspection
of the genitals ; and the mouth, anus, nostrils, and eyelids gradually
open up. The amniotic fluid increases in amount and becomes slightly
turbid after the fifth month from the presence of desquamated material.

Fig. 19. — Pregnant uterus of four months’ gestation. (Redrawn from specimen in

Washington University Anatomical Museum.)

Physiology

Only a few essential facts need be recalled concerning the physiol¬
ogy of the previable stage of pregnancy. One of these is the marked
change that takes place in the maternal endocrine system. Almost
at once upon the impregnation of the ovum there begin to develop

ABORTION

in the pituitary gland and in ovary and uterus , changes of so marked a
character that even before the expected time of the next menstruation
there is evidence of a formation of hormones so excessive in amount
that large quantities of them are daily excreted through the urine,
making possible the recognition of the pregnancy by means of char¬
acteristic tests upon lower animals. Together with the anterior
pituitary hormone there is an outpouring of follicular sex hormone , the
former decreasing and the latter increasing with the advance of preg¬
nancy. In the ovary we find the development of a corpus luteum of
pregnancy which secretes a special hormone, lutein , that has a definite

influence upon the embedding of the ovum in the uterus. Occasionally,
as will be discussed in the chapter on etiology, conditions arise that
interfere with the physiological development of these internal secre¬

tions and thereby lead to fetal death and abortion.

CHAPTER V

PATHOLOGY OF ABORTION

HP HE PREVIABLE INTERRUPTION of a pregnancy must be re-
garded as in itself abnormal and pathological, but the gross and
microscopic changes involved can be considered under two heads:

(1) Those in which the abortion is completed without complication
followed by a return of the uterus to normal conditions within a few
weeks ;

(2) Those in which portions of the ovisac are retained for some
time associated with tissue changes in the retained material and alter¬
ations in the structure of the uterus.

Uncomplicated Abortion

Certain changes may show in the ovisac depending upon t lie under¬
lying causes, but these will be considered more fully elsewhere. If
abortion is complete, we are primarily concerned with the rapidity
and extent of regeneration of the uterine mucosa. Interesting studies
have recently been made on this subject especially by Russian investi¬
gators. Jakowleff made a study of the uterine mucosa in 40 patients
three to twenty-nine days after abortion. This showed that after a
pregnancy was terminated by curettement, regeneration was rather
slow.

Epithelialization of the wound surface begins about the eighth or
ninth and is not completed until the twentieth day. Remnants of
decidua compacta and spongiosa were found up to the sixteenth day.
They play no part in the regeneration and for the first six or seven
days are found to contain glycogen. Krupennikow and Leitschuk
made some auxiliary investigations after such an operative abortion
with a second curettement up to 20 days later. They found full re¬
generation at the end of the third week. The stroma of the endo¬
metrium developed partly from the decidua and partly from the inter¬
stitial tissue of the glands. The surface epithelium regenerating from
its remnants usually covered the entire uterine cavity in seven to
ten days. Belgajeva and Golubcin report that in 42 cases of curet¬
tage after operative abortion necrotic decidual tissue was sometimes
removed as late as the twelfth day. Portions of the decidua may be
used to rebuild the endometrium. Regeneration of the uterine glands
begins on the fifth day but is sometimes retarded by the more slowly
regenerating endometrial stroma.

ABORTION

Retained or Incomplete Abortion

Under the head of missed abortion and molar pregnancy will be
found a more detailed description of the special pathologic changes
involved in these conditions. At this point we will consider only the
changes that occur in fetal, placental and uterine pathology when
portions of the ovisac are retained.

The Fetus. — Where abortion occurs in the earlier months of preg¬
nancy, changes in the fetus are not frequently found except in the
case of blighted ova. From the third to the sixth month, however, we
may note certain pathological variations. Rigor mortis has been ob¬
served in this period. It sets in within two hours after fetal death
but is already over in about ten to twelve hours while in the adult
this change is most pronounced twenty-four to thirty-six hours after
death. This is probably due to the difference in the surrounding tem¬
perature.

Maceration presents a peculiar non-bacterial softening of the tis¬
sues. It is more pronounced and frequent in fetuses of the last half
of pregnancy, and may be divided into three stages. In the first
stage the epithelium is raised in larger or smaller blisters containing
a yellowish or blood-tinged fluid. In the second stage of maceration
the blisters have opened and the skin is denuded in areas. In the
third stage of maceration the deeper connective tissue is edematous
and infiltrated with blood pigment so that the fetus has a dirty
brown-red color ( fetus sanguinolentus) . The internal viscera at this
period of maceration show marked liquefaction and the contours of the
various organs are less well defined. The umbilical cord at an early
stage shows thickening through edema and bloody infiltration (Fig. 20).

Mummification is a condition in marked contrast to maceration,
since here the body fluids are not added to but on the contrary, are
dried up, leaving the fetal structures shriveled, reduced in size and
often flattened out. This change occurs in younger embryos between
the third and fifth month. If associated with a twin pregnancy, such
a mummified fetus may be retained until normal birth, when it is
expelled as a flattened fetus ( fetus compressus ) (Fig. 21).

Over a longer period of time through the process of liquefaction of
the softer tissues in fetuses between the third and sixth month, all
but the bones of the skeleton may be absorbed and such bones may be
retained within the uterus for long periods of time. They may even
work their way into the wall of this organ and become embedded there
for years. It occasionally happens that in the evacuation of the
uterus in the middle months of pregnancy, particularly if the cervix
is not well dilated, the head of the fetus may tear off and be retained
for many months.

PATHOLOGY OF ABORTION

Sometimes in fetuses of 20 to 28 weeks' gestation, the entire body
becomes infiltrated with calcium salts so that a lithopedion is formed.
Niirnberger cites six such cases. This process is, however, more com¬
mon in tubal pregnancy.

Finally there is described so-called spontaneous decapitation of the
fetus with intact membranes, due, according to Streeter, to defects in
the germ-plasm. Many of these embryonal defects and amputations
were formerly attributed to amniotie adhesions or bands. Streeter
has definitely shown that the change is primarily in the germ-plasm
of the fetus and that the adhesions and bands are due to agglutina¬
tion of the degenerated areas of germ-plasm with the amnion itself.

The Placenta.— Where portions of the placenta have been retained
we find considerable variation in the histologic picture. The epi-

Fig'. 20. Fig-. 21.

Fig-. 20. — Fetus sanguinolentus. (Redrawn from Mall.)

Fig. 21. — Fetus compressus. (Redrawn from Halban-Seitz. )

thelial covering of the chorionic villi frequently shows almost a pro¬
liferating tendency (Fig. 22). While the Langhans cells are usually
completely absorbed, the syncytium may form buds of considerable
size that show normal staining qualities and a tendency to remain at¬
tached to and even slightly embedded in the mucosa. Occasionally
the layer of Langhans cells remain alive and form small islands of
ectoderm.

Quite characteristic of retained placental villi is the appearance of
connective tissue surrounded by a layer of fibrinous blood clot (Fig.
23). The epithelial covering may be completely absorbed, while the
connective tissue, although losing all nuclear elements, can be recog¬
nized by its different staining qualities and retains its irregular, ovoid
or sausage-shaped form within the blood clot. This hyaline degenera-

ABORTION

Fig-, 22.— Section through retained placenta, showing- continued proliferation of
syncytium, anemic chorionic connective tissue, and decidua with pronounced round
cell infiltration.

Fig. 22. — Section of abortion products, showing chorionic villous shadows encapsu

lated in a blood clot.

PATHOLOGY OF ABORTION

tion of the villous stems and their branches presents a characteristic
histologic picture (Fig. 24). The chorionic vessels also show charac¬
teristic changes consisting of concentric proliferation of the intima
with occasional round cell infiltration or hyaline degeneration of the
vessel walls. No noteworthy pathologic changes occur in the mem¬
branes. They remain intact for considerable periods of time.

Placental Polyp.— (Fig. 25.) The relative frequency of placental
polyp following abortion justifies more detailed pathologic considera¬
tion. These polyps vary in size from two to six centimeters in diam¬
eter, have a flattened or ovoid shape, and are attached by a broad
base usually to the upper portion of the uterine body. In a few

Fig'. 24. — Section of degenerated chorionic villi with infected necrotic decidua.

rare instances they mav be as large as a man’s fist. Their surface is
covered by a light brown fibrinous layer and their center contains,
for the most part, a dark red organized blood clot with some irregular
placental tissue visible at the base where the polyp is attached. They
often show concentric layers due to the agglutination of additional
layers of coagulated blood (Fig. 26). In this way the polyp some¬
times grows larger and larger until it dilates the cervical canal and
becomes visible at the external os.

Langhans explains the formation of polyps in the following man¬
ner. “When the ovisac is expelled decidual remnants with arterial
bundles remain behind. These arterioles empty into the uterine cavity
and the blood seeping out of them forms a voluminous adherent clot.

ABORTION

Fig-. 25. — Diagrammatic picture of a placental polyp in the uterus. Note the
broad base of attachment and the piled-up layers of fibrinous blood springing
from it.

Fig. 26. — Section of a placental polyp, showing necrotic chorionic villi, round cell
infiltration, and characteristic layered appearance of the blood coagulum.

PATHOLOGY OF ABORTION

This does not entirely occlude the arteriole but forms a sac into which
new blood flows with gradual enlargement of the polypoid mass.”

Iieynemann believes that the incidence of such polyps is increased
by uterine relaxation and a greater tendency to thrombosis. Occa¬
sionally the placental retained tissue in these polyps shows active
proliferation and even superficial penetration of the uterine wall. In
these cases, especially if the abortion ovum shows evidence of hydatid
change, we must be on the lookout for a possible development of a
chorio-epithelioma.

V?V V:\', C.'

■ '

*, >}'- ' hr -** V

,-?> ay"

mir- ■

ft .% S> r, '*< \\ vp A ,

VjMSW

*< i If*;'.

Fig. 27. — Section of postabortive endometritis. The uterine glands show the
typical corkscrew proliferation of early pregnancy with a small island of decidua
in the center of the section.

Post-abortive Endometritis. — The most common pathological lesion
following abortion is that of so-called post-abortive endometritis or
subinvolution. In the gross examination of such a uterus we find a
markedly thickened uterine mucosa with a uterine wall that also is
increased in size, and is softer and more liyperemic. The curette brings
away considerable material varying in consistency from almost car¬
tilaginous tissue to soft mucous particles. In the firmer pieces ex¬
amined microscopically, we find degenerated chorion villi and plaques

ABORTION

Fig. 28. — Section of acute septic endometritis with pronounced leucocytic infiltra¬
tion. Aj, Endometrium of uterus removed at operation. B, High power magnification
showing infiltration by leucocytes.

PATHOLOGY OF ABORTION

of decidua cells. In the softer particles we find uterine mucosa show¬
ing* the typical corkscrew-like proliferation of the uterine glands
(Opitz) (Fig. 27). The uterine mucosa shows the marked round cell
infiltration and hyperemia of a chronic infection. The decidual tissue
shows a varying picture. In some areas it appears as an island of
decidua cells, in other areas it is surrounded by or embedded in
uterine mucosa. Often these cells show degenerative changes, becom¬
ing smaller, more spindle shaped and staining only faintly with a
somewhat swollen nucleus. The round cell infiltration invades and
separates these decidual bundles. In the presence of more active in-

* t- ■

'*<4 ^

Fig-, 29. — Section of syphilis of the placenta. Characteristic of this disease are
the round or club-shaped villi, the blanched appearance of the connective tissue, and
the deeply staining spots in the syncytial covering.

fection polynuclear leucocytes are present throughout the mucosa and
the blood vessels are considerably increased in size and number (Fig.
28).

The uterine wall histologically shows the typical picture of a sub¬
involution with some edema of the fibro-muscular coat and numerous
open blood vessels.

While careful search of the curetted parts will usually reveal a few
islands of degenerated chorionic villi, it occasionally happened that
only decidual elements are found, and, in a few instances, if consider-

ABORTION

able time lias elapsed between the abortion and the curettage all
histologic evidence of the preceding pregnancy may be absent. In
such cases we see only the hyperplastic endometrium with chronic
infection.

Other Conditions. — Syphilitic changes in the placenta are usually
not pronounced before the twenty-fourth week although we may find
a tendency to club-shaped villi and obliterative endarteritis (Fig. 29).

Marta describes four cases of placenta marginata in abortion. All of
these showed evidence of a previous infection, but without symptoms of
constitutional reactions. He believes that such placentae develop from
inflammatory rather than mechanical causes.

CHAPTER VI

ETIOLOGY OF SPONTANEOUS ABORTION

IIE SUBJECT of the causative factors in spontaneous abortion is

A one of great complexity since a great variety of conditions may
be responsible for the early interruption of pregnancy. Unlike such
writers as Verrucoli, who in a series of 207 abortions could find no
etiological factor in over two thirds, I have found that a causative
factor is usually in evidence. The difficulty is rather that so many
possible factors are present that it is often difficult to decide which to
stress as of the greatest importance. While much additional research
will have to be done before the causes of abortion are fully under¬
stood, considerable headway has been made in the past twenty-five
years. The chapter on etiology in my original monograph (1910)
must be completely discarded to make way for the newer ideas on
defective germ plasm, endocrine pathology and dietary insufficiency
as factors in spontaneous abortion. Certain of the factors in the
etiology of abortion are temporary and may not affect succeeding
pregnancies ; others, on the other hand, are apt to recur with each
gestation or be constantly present so that abortion occurs repeatedly.
The term “habitual abortion ” has been applied to this latter condi¬
tion. The analysis of factors entering into the production of an abor¬
tion is sufficiently complicated without attempting a further subdivi¬
sion into simple and habitual abortion. At the conclusion of this
chapter I will summarize briefly those etiological factors that are apt
to be recurrent, and thus lead to repeated interruptions of pregnancy.

The diagnosis of the cause of abortion in a particular case is doubly
difficult because in so many instances a combination of factors enters
into its production. Let us take, for example, one of the simplest,
that of abortion following a sudden fall. We know that only a rela¬
tively small number of women who have such an accident will abort.
In the presence of other factors, however, such as unusual irritability
of the uterus, the time relation of the occurrence to the menstrual
period, or local pelvic conditions, such as fibroid uterus, prolapse,
cervical tears, predisposing go a loosening of the placental attach¬
ment of the ovum, an abortion may result. Similarly we have many
instances in which both the embryo and the mother are subjected
to some form of injury and it is impossible to say which of the two
was the predominating cause for the abortion.

ABORTION

Classification

Niirnberger, in his chapter on etiology in the Halban-Seitz Hand-
buch, has retained the general division, dating back to the days of
Morgagni, of ovular and maternal causes of abortion. T have preferred
to consider these two as subdivisions of the general group of primary
or fundamental causes, and to add thereto a second group of second¬
ary or exciting causes. The main subdivisions of this etiologic classi¬
fication would then be as follows :

A. Primary or Fundamental Causes
I. Ovulogenic:

(1) Fetal

(2) Placental

IT. Maternal:

(1) Constitutional Factors

(2) Endocrine Disturbances

(3) Infections

(4) Pelvic Pathology

(5) General Diseases

(6) Chemical and Physical Agents

(7) Operative Procedures

E. Secondary or Exciting Causes

(1) Physical Trauma

(2) Thermic Irritation

(3) Psychic Trauma

A. FUNDAMENTAL CAUSES

I. Ovulogenic

(1) Fetal, — In attempting to trace the factors leading to spontane¬
ous abortion to their ultimate causes, we have been led more and
more to realize that these may antedate the pregnancy itself and de¬
pend upon the sex cells, male and female, or upon some special in¬
compatibility between the two, making the impregnated ovum unable
to proceed to normal development. The investigations of Mall and
Streeter on early abortion ova have not only demonstrated the rela¬
tive frequency of such ovulogenic factors but have thrown some light
upon their origin. Unfortunately the average physician too seldom
examines and reports on the expelled ovisac. If this were done, I am
sure it would corroborate my experience and that of others, that in
early spontaneous abortions one of the most common causes is ar¬
rested development of the ovum, leading to its death in the first few
weeks. Often the little ovisac contains no visible fetus, or a mere
vesicle in place of the embryo. Of human abortion ova dating from
the first month, Mall found only a fifth normal, and from the second
month only a half normal. The lower mammals with large litters
regularly show a large percentage of defective ova that die early in

ETIOLOGY OP" SPONTANEOUS ABORTION

their development and are, for the most part, absorbed by the time
the normal embryos reach maturity and are expelled. Evidence of
this is cited by Corner who counted the number of corpora lutea just
after ovulation, and found them always more numerous than the litter.
In the ferret he found in 165 animals a total of 1,643 corpora lutea
with 1,246 embryos, a fetal mortality rate of 24 per cent. In rabbits
Hammond found an average of nearly ten corpora lutea per animal
with an average of six offspring at birth, a prenatal mortality of
about 40 per cent. In dairy cattle and horses, as related by Prof.
Williams in Chapter III, indications point to similar prenatal loss,
since mating in healthy animals does not always lead to a successfullv
terminated pregnancy. Following 28,000 matings in horses, Robinson
calculated a prenatal mortality of 48 per cent.

Macomber uses the term “ defective germ-plasm” as applied to this
factor in abortion and notes that it occurs with greater frequency
among couples Avith Ioaa- fertility. In defining defective germ plasm,
Streeter says: “It must be understood that defective plasm is de¬
scribed on the bases of behavior rather than microscopical appear¬
ance. The defective egg is one that does not develop properly, rather
than one av i t h a characteristic histologic appearance of tissues.” In a
recent discussion of this subject A\7ith me, Dr. Streeter stated: “At
times the trophoblast is defective, at times the inner cell mass may
be defective and sometimes the fault lies in both of them. At the
start there is merely cell division of the impregnated ovum without
growth. A certain portion of the cell mass then separates out into the
trophoblast and the fate of the t\A7o becomes distinct. The trophoblast
makes its own blood supply and connective tissue in which the embryo
does not directly participate. As to the relative frequency of defects
in the trophoblast and embryo, accurate data are not available. All
varieties and degrees of defect may occur, sometimes caudal, some¬
times at the head end. If the building materials are good then the
egg is good. In such cases endocrine influences should not be poAver-
ful enough to disturb normal development. In defective germ-plasm
preconceptional factors are probably more important than post-con-
ceptional. Trophoblast defects are fewer in number and less impor¬
tant than embryonal defects. If one-half the trophoblast is good it
should suffice for the embryo.”

In the opinion of Huntington working Avith Streeter, defective
germ-plasm is more apt to occur Avhen the individual is over or under¬
nourished and is associated often with endocrine disturbances. In 104
abortion ova studied by Huntington, he found 82 ova Avith faulty
developments.

ABORTION

It has long been noted that abortion ova are more apt to occur in
male fetuses and Kirstein believes that there may be a hereditary
factor that makes them more easily killed by external, harmful influ¬
ences. If we could determine chemically the nature of the “lowered
resistance77 factor in males, measures might be devised to lower the
number of such abortions. A fatalistic attitude is sometimes assumed
by the women who suffer from this type of habitual abortion. Leh¬
mann tells the story of a patient, who had had one living girl and
four male spontaneous abortions, who refused to take his sedatives,
saying: “If it is going to be a boy, your medicine will not help, and,
if it will be a girl, I have no need for your medicine.77

Riddle attributes the higher abortion rate in males to the greater
vitamin and metabolic requirements of that sex. Especially large
quantities of vitamin B are said to be necessary for the male. Genetic
weakness of the male as an explanation of greater fetal death rate
is untenable. Furthermore the hormone environment of the male
fetus in a female host is claimed to be a disadvantage, since the pla¬
centa is not a barrier but a filter, and the mother 7s blood possibly
reacts to the male fetus as to a foreign body, producing an anti-
testicular substance antagonistic to the fetus.

Diminished vitality in the ovum or spermatozoon has also been men¬
tioned as an etiological factor. Mayer believes that such an ovum
may lack the necessary aggressiveness to embed itself into the uterus.
The relative frequency of abortion in cases of irregular menstruation
may possibly be due to the occasional impregnation of a post-mature
ovum. It is, however, a definite clinical observation that abortions
occur oftener toward the end of the reproductive period in women
over forty years, and that this may be due to diminished vitality of
the ovum and the maternal tissues.

G. L. Moench made careful histologic studies of pathologic sperma¬
tozoa and found that wives of individuals having a high percentage
of such sex cells are apt to show greater than average frequency of
abortion. The father is an important hereditary factor in abortion,
since deformities are more apt to be transmitted through him. Mayer
points out that the value of the impregnated ovum may be influenced
by the sperm of the father. The fact that the abortion ova as well as
over-size children are predominately masculine together with the evi¬
dence of sex determination by the sperm tends to the belief in a para¬
mount importance to be credited to the influence of the sperm upon
the growth. Of unusual interest are the two cases of repeated abor¬
tion with blighted ovum reported by Sanders, in which no reason
could be found in the wife. The husband showed definite pus in the
semen due to a non-venereal prostatitis. After massage treatment

ETIOLOGY OF SPONTANEOUS ABORTION

the pus disappeared and the next conception, a few months later, was
carried to term in both cases. This tends to corroborate the work of
Moench. Sanders refers to the experiment done by Macomber, who
found that after bilateral vesiculectomy in rats, the female impreg¬
nated by them showed an increased tendency to abortion.

Henkel declares that even with ovum and spermatozoa normal, the
two may be mismated and lead to faulty development, since it is fre¬
quently noted that these same individuals may produce normal, full-
term children in a later marriage.

Thus far we have been considering the internal factors in the pro¬
duction of fetal death that leads to abortion. External factors also
exist, which, if associated with relatively minor disturbances present
in the mother, will result in fetal death and thus eventually lead to
abortion. Such harmful substances may be of an infectious, a toxic,
chemical or physical nature. While the fetus, in the early months of
its development, possesses a certain immunity to various maternal
infections, these may at times be transmitted through the placenta
and lead to fetal death. The same applies to the passage of certain
chemical substances, such as carbon dioxide, chloroform, phosphorus
and mercury, and toxins, such as those of diphtheria and tetanus,
which, without appreciably damaging the mother, may in rare cases
be responsible for fetal death. Hyperpyrexia and the shock of light¬
ning may at times have a similar lethal effect. Nuernberger includes
as a cause of fetal death certain metabolic deficiencies, such as the
absence of oxygen, albumen, fat, carbohydrates, mineral salts, and
maternal hormones. During the Great War there was evidence of the
influence of such metabolic deficiency upon the ovum leading to
abortion.

Multiple pregnancy is a frequent factor in premature labor and
may at times lead to late abortion. This is more apt to occur if there
is an excess of amniotic fluid or if there are three or more fetuses
(Fig. 30).

(2) Placental Causes. — It is indeed hard to draw the line between
those conditions producing fetal death, that are due inherently to the
ovum and those for which the placenta is responsible. Mall is in¬
clined to believe that a large percentage of cases of “blighted ovum”
are due to factors in the trophoblast. In such pathological embryos
he finds the villi atrophied and irregular, the chorion either thin and
transparent or thick and hemorrhagic, and a considerable increase in
the amniotic fluid with a granular deposit in the liquor amnii. Further-
discussion of the pathologic factors underlying the “blighted ovum’1
will be found in the chapter on Missed Abortion.

ABORTION

Litzenberg believes that a vast majority of abortions can be traced
to abnormalities of the endometrium, decidua and placenta. In some
instances, however, these uterine changes are secondary to other fac¬
tors such as focal infection, acute inflammation, heart disease, etc.
“It is evident,” says Whitehouse, “that impairment of nutrition from
faulty implantation, absence of essential food factors and the exist¬
ence of lethal toxins are potent factors in abortion.” That fetal death
may be secondary to placental changes of great significance is stressed

by Henkel. Chorionic villi may have obliterated vessels and there
may be hemorrhage and edema indirectly producing fetal death.

Placenta Previa , although more often responsible for interruption of
pregnancy after the period of viability, does occasionally give rise to
abortion between the third and sixth month. Rlientner and Pigeaud
state that in abortion of three to five months gestation, placenta
previa is the cause in 15 per cent of the cases. The abortion at this
stage is due to changes in the decidua. By a reduction in the size of
the decidual mass over the cervix, intervillous spaces and villi are
exposed, and the bleeding that results therefrom leads to the expul-

ETIOLOGY OF SPONTANEOUS ABORTION

sion of clots from the cervix producing contractions of the uterus by
reflex action. These authors believe that the majority of placenta
previas that go to term are at this stage of development lateral in¬
sertions and only later on cover the cervix completely. The early
central implantation is apt to lead to abortion. Six cases of definite
placenta previas were reported by them in pregnancies between the
third and fifth lunar month. In two cases the diagnosis was con¬
firmed before the abortion and in the remaining four the history and
examination of the ovisac left no doubt that a placenta previa had
been present. I have seen two cases of abortion, attended by un¬
usually copious bleeding, that were evidently due to placenta previa
as shown by the flattened surface, hemorrhagic areas, and shape of
the placenta. In many of these cases the ovisac will be expelled in¬
tact, and careful inspection will confirm the suspicion of a low pla¬
cental implantation.

Fig-. 31. — Twisted umbilical cord producing- abortion. (Redrawn from Halban-Seitz. )

A twist of the umbilical cord has often been blamed for fetal death
and the resulting abortion. A careful check-up, however, will reveal
that in many of these cases the twisted condition of the umbilical
cord came about after the death of the fetus, chiefly as the result of
necrotic changes in the cord, leaving it without any elasticity to
counteract twists that might naturally develop. In Fritscli’s case the
patient had five abortions in all of which torsion of the umbilical cord
was noted (Fig. 31).

The suggestion was made by Aschner that some cases of habitual
abortion were due to primary diseases of the placenta. Some of these
cases he believes, heretofore classified as toxic nephritis, should be ex¬
plained as toxic albuminuria of placental origin. This subject will
require additional research before a proper estimate of its importance
can be given.

The pathology of hydatid mole will be considered in another chapter
but it must here be emphasized that in the vast majority of cases of
hydatid mole the pregnancy does not proceed beyond the third month.

100

ABORTION

Only if the area involved by the hydatid change is relatively small
and not situated beneath the umbilical insertion, can the fetus con¬
tinue to develop. Less than one-half dozen such pregnancies going
to term are recorded in literature. Hydatid mole is essentially due to
a neoplastic proliferation of the trophoblast resulting in fetal death
and spontaneous expulsion of the abortion ovisac with its grape-like
appendages. Meyer and Mall found eight such moles in 2,400 speci¬
mens of abortion.

Inflammatory changes of the decidua, known as deciduitis , may result
from infectious conditions in the endometrium over which this decidua
has developed. The fact that round-cell infiltration is commonly
found in all decidua examined in abortion ova will not be taken as
evidence that the inflammatory condition is a primary factor, since
this may have arisen during the process of abortion. The question is,
however, not so much whether these endometrial changes are responsible
for the abortion, as how often the blame lies with them. Among animals
it has been shown that the presence of infection exudate is of prime
importance in causing abortion. In human beings, however, Hunting-
ton, Yerrucoli and others believe that such a preceding deciduitis due
to endometrial infection is responsible for not over one in twenty-five
abortions.

XI, Maternal Causes

(1) Constitutional Factors.—

Blood Groups. — Careful study of individuals according to their blood
group has shown a tendency to abortion in some instances where there
was a difference in the blood group of husband and wife. Italian in¬
vestigators have been primarily interested in this question. Tranquilli-
Leali studied 41 habitual abortions without explainable cause and
found in 38 an incompatibility of blood groups of husband and wife,
and only three pairs with the same group. He compares this with
29 couples who had normal full-term children in whom there were
20 compatible and 9 incompatible blood groups. Paroli also believes
that such a constitutional disharmony between mother and father
may be a cause of abortion. He studied 27 cases of spontaneous abor¬
tion in which lues and other factors could be excluded and found that
in 26 out of 27 the parents belonged to different blood groups. In 14
cases they were group I and II ; in 5 cases group I and III ; in 5 cases
group III and IV ; and in 2 cases, group I and IV. Additional data
on a large scale are necessary before this difference in blood grouping
can be definitely accepted as a cause of abortion, since as Mayer
points out the placenta as intermediary would doubtless prevent any
harmful effect due to the difference in blood groups. Nevertheless,

ETIOLOGY OF SPONTANEOUS ABORTION

101

growth would probably be easier if both spermatozoon and ovum
come from individuals of the same group.

Dietary Deficiencies. That the nutrition of the mother must play an
important part in the development of the ovum and hence be re¬
sponsible at times for abortion is self-evident. It was discovered that
starvation early in pregnancy leads to fetal death in rats in many
instances. Macomber and Vignes have shown that calcium deficiency
may be responsible for abortion. E. P. C. Williams found that a dis¬
turbance of carbohydrate metabolism was present in many cases of
unexplained abortion. In nineteen women who had had two or more
such spontaneous abortions and who were again pregnant, and in
twenty who also had had frequent abortions but were not pregnant
at the time of examination, he did a sugar tolerance test and found
that it was greatly lowered in 90 per cent. Only 2 of the entire series
of 39 cases were normal.

The reason that this factor has been overlooked is that such women
on ordinary diet show no leakage of sugar. Williams does the sugar
tolerance test in the morning, giving one piece of toast and tea, with¬
out sugar four hours before beginning the test. Then 100 grams of
glucose is given in one-half pint of water, and samples of blood are
taken everv one-fourth hour for the first hour and every one-half
hour for the next one and one-lialf hours. The urine is also collected
at the end of one and two hours, examined, and the total sugar leakage
is estimated. The blood sugar curves obtained by these readings
were found abnormally high in 14 cases. Additional evidence, accord-
ing to Williams, of the significance of faulty carbohydrate metabolism
lies in the fact that under proper correction of these dietary de¬
ficiencies, 11 of the 19 women who had habitually aborted were car¬
ried to full term.

The newer work on vitamin deficiencies in diet together with their
effect upon fertility and other endocrine disturbances has led to the
belief that they might be responsible for many abortions. Evans and
Bishop found that vitamin E starvation caused death of the embryo
with disintegration and absorption of the placenta, membranes, and
decidual tissue. Urner believes that all vitamins may be a factor in
abortion. Thus far, however, most of the evidence connecting vita¬
min deficiency with abortion depends on therapeutic tests. We have
thus a number of investigators who found that by giving cod liver
oil, especially in the form of viosterol or vigantol, abortion could
sometimes be prevented. Ivlotz and Sanger cite instances of such an
apparent favorable influence of cod liver oil extracts. From Scandi¬
navian sources comes the suggestion of Vogt-Moeller to employ wheat
germ and wheat germ oil containing quantities of vitamin E as well

102

ABORTION

as vitamin A to prevent habitual abortion. Even with wasting dis¬
eases such as tuberculosis, however, mothers usually give birth to
fully developed babies. In this country, where all the needed con¬
stituents for a balanced diet are obtainable, dietary deficiencies prob¬
ably do not play a very great part in abortion, except in domestic
animals (Chapter III).

Age. Mention has been made of age as a factor predisposing to fetal
death. Dengler records an interesting case in a woman of thirty-
seven with a blood pressure of 195 over 125, but without any urinary
or blood findings pointing to nephritis, who aborted at the third
month. The placenta contained infarcts. Dengler considered that a
constitutional arteriosclerosis possibly of hereditary origin (since
both father and sister had similar conditions) was responsible for the
tendency to abortion.

Neurogenic hypertonicity. Experimental work has demonstrated
that the irritability of the uterine muscle to mechanical, thermic and
other forms of stimulation is greatly increased during pregnancy.
The presence of this high degree of irritability under conditions of
ordinary health shows an increase in some individuals to such a de¬
gree that the slightest trauma, nervous shock, etc., brings about
uterine contractions and leads to abortion. Individuals with exces¬
sive constitutional nervous irritability will usually show this in other
ways such as marked peristalsis of the intestine, increased urinary
frequency, or twitching of the body. Hirst points out that women
afflicted with chorea, epilepsy, hysteria and tetany are apt to expel
the product of conception prematurely. Under the head of secondary
or exciting causes of abortion we have considered a large number of
conditions that may bring about uterine contractions. External
trauma and psychic disturbances will in some individuals produce
not the slightest disturbance of the pregnancy. In fact it is amaz¬
ing what some individuals may tolerate in this way. Other individ¬
uals will respond even to slight shock or trauma with immediate abor¬
tion. The favorable therapeutic results produced by complete rest
and sedatives in certain individuals is strong evidence of the impor¬
tance of constitutional nervous hyperirritability as a cause of abortion.

(2) Endocrine Disturbances. — The significant changes that occur in
the endocrine system early in pregnancy make it easy to understand
that where disturbances occur in this system abortion may readily
result. Pituitary, ovary and thyroid are the endocrine organs that
most often show some pathology in their function. In every case giv¬
ing a history of previous spontaneous abortion the basal metabolic
rate should be determined before the next conception and repeated
during the early months of pregnancy. Frank believes that the follicle

ETIOLOGY OF SPONTANEOUS ABORTION

103

sex hormone test is also of considerable diagnostic value, and should
be done routinely in every case of pregnancy with a history of pre¬
vious abortion.

Insufficiencies of secretion in the anterior pituitary gland are in¬
directly responsible for some cases of abortion through arrested de¬
velopment of the uterus. In such women pregnancy does not readily
take place, and, when it does, the relatively small size of the uterus
leads to a tendency to abortion. Such infantile uteruses are usually re-
troposed ancl associated with a short posterior vaginal fornix. It not
infrequently happens, however, that after one such abortion the
uterus has sufficiently enlarged so that in a subsequent pregnancy the
child may be carried to term. Weinzerl cites six cases of habitual
abortion in women between twenty-four and thirty-three who had
such a hypoplastic condition of the uterus. Where conception occurs
in very young girls shortly after puberty the lack of growth of the
uterus is often responsible for abortion. In India and among Polish
Jews where early marriages are of common occurrence abortion is
frequent. As a possible explanation, Kermauner suggests incomplete
development of the decidua as well as diminished size of the uterine
cavity.

The pathological conditions influencing the secretion of ovarian
hormones are of the greatest importance. Of these ovarian hormones,
folliculin and lutein have thus far been isolated, and each has its
special function. It seems logical to assume that disturbances of either
will interfere with the imbedding and development of the ovum and
so be responsible for abortion. Fraenkel showed over thirty years
ago that the removal of the corpus luteum early in pregnancy tended
to interrupt it and concluded that this structure had an internal
secretion essential for the development of the gestation. Improper
function of the ovarian hormones can to some degree be ascertained
according to Frank, by the female sex hormone test.

It seems probable that alterations of the primary follicle secretion
is of less importance in the etiology of abortion than corpus luteum
insufficiency. The a priori assumption of a corpus luteum deficiency
in cases of habitual abortion has been confirmed by the clinical ex¬
perience of many observers. Weinzerl, Wagner, Patti and many others
have been able to prevent abortion by the administration of corpus
luteum preparation during the earlier months of pregnancy. Whether
the benefit of these substances is due to a specific influence upon the
development of the ovum or to a lowered irritability of the uterine
muscle produced by them is still undecided. The fact that with a
discontinuance of treatment in the 4th and 5th month, abortion may

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ABORTION

nevertheless occur, points rather to a sedative influence of the corpus
luteum than to a specific effect. Candela has done experimental work
pointing to a quieting effect of the corpus luteum on a uterus irritated
by pituitary extract. A somewhat similar sedative effect has been
noted after the ingestion of placental extracts and these too have been
recommended as agents for the prevention of abortion.

The condition of the thyroid gland, especially in the earlier months
of pregnancy, is a matter of considerable importance, so that Litzen-
berg and others believe in a routine basal-metabolism test in preg¬
nancy. If this test shows a reading between minus 12 and minus 30,
thyroid should be given in small doses and will often be a factor in
the prevention of abortion. Abruzzese found faulty functioning of
the thyroid gland in 16 out of 30 women who had had an abortion
without physical cause. In his 16 cases, a basal metabolism test
showed 5 times that it was too low, and 11 times that it was too high.
Huntington mentions a deficient thyroid secretion as responsible for
cases of abortion. The frequency of abortion in the hyperthyroid
women of Switzerland together with the correction of this condition
by a thyroidectomy has shown the importance of Basedow’s disease
as an etiological factor. Mayer calls attention to the fact that ex¬
perimental injection of thyroid extract tends to shorten pregnancy
while a thyroidectomy tends to prolong it. He advises giving iodine
in cases of habitual abortion due to hyperthyroid secretion.

Concerning the influence of other endocrine organs such as the
thymus, the adrenals and epiphysis so little is known at present that
no statement concerning their influence upon abortion is justified.
Nuernberger in the Halban-Seitz Handbuch cites the few clinical ob¬
servations upon this subject thus far recorded.

(3) Infections. — Many acute infectious diseases have a deleterious
effect upon pregnancy, and may indirectly be a factor in its interrup¬
tion through the associated toxemia and hyperpyrexia. Typhoid
fever, cholera, scarlet fever, smallpox, erysipelas, encephalitis lethargi-
ca, and malaria produce abortion in about one-half of the pregnancies
associated with these diseases. Of special danger to the pregnant
mother is croupous pneumonia, and the severer type of influenza pneu¬
monia, as reported in the epidemic of 1918. In these chest conditions
the cyanosis of the mother is very apt to produce fetal death. It
should be noted, however, that in all these acute infections of the
mother the likelihood of an interruption of the pregnancy becomes
greater with each month of gestation, and is greatest in the last three
months.

ETIOLOGY OF SPONTANEOUS ABORTION

105

Malta fever is a relatively rare disease, but special interest con¬
nects it with the question of abortion since the organism found in
Malta fever ( Bacillus 'wielitensis ) has been found to be identical with
Brucella abortis, or Bang’s bacillus, responsible for contagious abor¬
tion in cattle. It has been claimed by some observers that women,
in tending cases of contagious abortion in animals, may themselves
acquire the disease and have an abortion if they become pregnant.
W hitehouse reports such a case in which he found the specific organ¬
ism in pure culture in the mucopurulent vaginal discharge. Simpson
and Frazier reported five cases of repeated abortion, four of whom
gave a history of obscure undiagnosed fever. All had partaken of
raw milk and showed an agglutination test pointing to infection with
the specific organism of contagious abortion. Cornell and DeYoung-
found agglutinins in the placental blood in one patient who had
aborted at two months but in 22 others this test was negative. At
the present time therefore it would seem that this organism does not
play an important part in the etiology of abortion even in those com¬
munities where raw milk is drunk from cattle infected with this
disease.

Focal infection, Avhile not a common cause of abortion, would seem
to be a factor in a certain number of women having a tendency to
repeated spontaneous expulsion of the ovisac. In every case of
habitual abortion, therefore, it is well to make a careful investigation
of the more common sites for focal infection. Curtis in 1916 was one
of the first to call attention to the importance of focal infection as
an etiological factor. Septic processes about the gums and posterior
nasopharynx were found to be particularly associated with a tendency
to abortion. The evidence in favor of such a relationship between
the two conditions was based upon the finding of streptococci in the
placenta in these cases, and the clinical experience that after removal
of the focus abortion did not recur. Keith experimentally used cul¬
tures of streptococci obtained from the tonsils and placenta of a
woman who had had five spontaneous abortions. He injected these
into four pregnant rabbits and all four aborted, while of ten pregnant-
rabbits in whom injections were made from cultures of other organ¬
isms, none aborted. He concludes that foci of infection may harbor
streptococci that possess properties favorable to the production of
spontaneous abortion.

Nickel and Mussey isolated a green-producing streptococcus from
infected teeth and tonsils and injected cultures of this organism into
pregnant guinea pigs. In six out of seven such cases abortion re¬
sulted, with streptococci found in the blood in 50 per cent, in the

106

ABORTION

uterus in 83 per cent and in the fetus in 50 per cent. As a control
they used material where the focal infection produced arthritis but
not abortion and found experimentally that abortions were not pro¬
duced by injections of cultures of this organism. They believe, there¬
fore, that the premature emptying of the uterus in these animals was
apparently due to the elective localization and growth of the strepto¬
cocci in the placental site, and to the death of the fetus from in¬
vasion of its blood stream by this organism. The favorable clinical
experience of Curtis with his first three cases has been corroborated
by other gynecologists and has definitely established focal infection
as an etiological factor in abortion.

Syphilis demands first consideration under the head of chronic in¬
fections responsible for abortion. A generation ago syphilis was
considered the most important etiological factor in the premature ex¬
pulsion of the ovum. Even at present we find many able clinicians
who consider women who repeatedly abort as probably infected with
a latent form of syphilis. The mistake is commonly made of not ob¬
taining a careful history in these cases as to the period of gestation
at which the ovum was expelled. While syphilis is undeniably the
most important factor in the premature expulsion of a macerated
fetus in the last three months of pregnancy, it is only in exceptional
cases the cause of abortion in the first three months. It cannot, how¬
ever be denied that so insidious an infection as syphilis may have a
harmful effect upon the germinal cells of the parents and thus indi¬
rectly have an unfavorable influence upon the development of the
impregnated ovum.

According to Litzenberg the Spirochaeta pallida is seldom found in
the first three months of gestation. At the University of Minnesota
Clinic, Adair found that the percentage of abortions in luetic women
was not any greater than in women who did not have such an infec¬
tion. In the much less frequent abortions occurring between the
fourth and sixth month of gestation, syphilis is a far more important
factor and probably in over one-half of these interruptions of preg¬
nancy we will find the cause in a previous syphilitic infection of the
mother. The work of McCord among the colored population of the
South would tend to indicate that in this race syphilis assumes a
malignant form and is probably productive of abortion earlier in
pregnancy and in a larger number of cases.

In England, Pye-Smith found that out of 485 cases of pregnancy in
untreated syphilis there were 63 abortions or 13 per cent, which is
about the average of abortions in the population as a whole and would

ETIOLOGY OF SPONTANEOUS ABORTION

107

indicate that maternal syphilis is apparently of no great importance
as a cause of abortion. On the other hand, there were 73 stillbirths
in this group, 15 per cent, which, compared to an average of about
3 per cent of stillbirths for the population as a whole, indicated the
importance of syphilis as the cause of late fetal death. “ Syphilis of
the nervous system,’7 declares Belote, “does not cause fetal death or
predispose to miscarriage any more than ordinary late syphilis.”
According to Marin syphilis is rarely a factor in abortion up to the
fourth month. Between the seventeenth and the twentieth week it
produced not cpiite 2 per cent of abortions; between the twenty-first
and twenty-fourth week, 7 per cent; and between the twenty -fifth
and the twenty-eighth week, 20 per cent.

Tuberculosis will rarely lead to an abortion before the period of
viability. It is practically only where some acute flare-up has occurred
leading to a pneumonia, that the pregnancy is interrupted spontaneously.

Pyelitis will occasionally produce a disturbance of pregnancy in
the middle months that leads to the premature expulsion of the ovum.
This is in part due to the toxemia associated with the infection and
in part also to the frequency of ureteral colic arising either spontane¬
ously or as a result of ureteral catheterization. The close relationship
between the sympathetic nerves supplying ureter and uterus not in¬
frequently leads to rhythmical contractions of the uterine muscle in
sympathy with the peristalsis of the ureter and these rhythmic con¬
tractions may, if not quieted by opiates, produce an abortion.

(4) Pelvic Pathology. — Various faults of development and patho¬
logical processes in the genital tract may predispose to abortion.

Mention has already been made of the infantile uterus. A similar

«/

reduced capacity of the uterine cavity exists in the bicornuate uterus
or one with septate cavity. The restricted space for ovular develop
ment in such an organ tends to abortion.

The lacerations of childbirth sometimes have an unfavorable effect.
This is particularly true of tears that destroy the pelvic floor support
and lead to prolapse of the uterus, and to those that involve the cervix,
extending to the parametrium on one or both sides, thus leaving the
contents of the uterine cavity exposed to infection and trauma. In
pronounced laceration of this sort the abortion may be attributed with
fair certainty to this cause; but in less severe tears it may be far more
difficult to draw conclusions since many women with such lacerations
carry their offspring to full term without difficulty.

Jahnke has stressed the frequency of abortion following vaginal
cesarean section in which the internal sphincter fibers of the cervix

108

ABORTION

were cut and poorly united. Leonard, in reviewing the results of
amputations of the cervix, states that where pregnancy followed such
operations the percentage of abortion and premature labors was in¬
creased. A similar report is given by Sfameni. We therefore feel
that where the laceration or operative procedure has resulted in a
separation of the circular fibers near the internal os of the cervix, the
retention of the ovisac within the uterine cavity is rendered more
difficult ; therefore abortion not uncommonly results.

Retroversion of the uterus is commonly blamed for abortion but
this is justified in only a small percentage of cases. Since retroversion
occurs in about one-fourth of all women who have had children and
since, with but few exceptions, during pregnancy such a retroverted
uterus will spontaneously correct itself, I agree with Plass that this
etiological factor should not be stressed. Where, however, the re¬
troversion is associated with rather extensive pelvic adhesions, the
uterus may become partly incarcerated in the cul-de-sac and through
pressure that is thus brought about, may lead to abortion (Fig. 32).
Where the retroversion is associated with considerable pelvic relaxa¬
tion, interruption of a pregnancy is more likely to occur. In these two
groups of cases, I think we are definitely justified in attempting to
hold up the uterus in its proper position, provided that all manipula¬
tions for this purpose are done with extreme care to avoid producing
uterine contractions. This can be accomplished by wearing a pessary
for the first four months of pregnancy and daily assuming the knee-
chest position (Chap. VII, Fig. 33). In some instances the adhesion
may be so firm that local measures fail to loosen them and the only
escape from an incarceration of the pregnant uterus lies in a surgical
correction of the retroversion with opening of the abdomen and divi¬
sion of the adhesions by the scissors.

Myomata are more common in sterile women but the association of
pregnancy and myoma is sufficiently frequent to make each case a
matter for careful consideration. In general it may be said that if
the myomata are few in number, if they are relatively small, and if
they are situated at some distance from the uterine mucosa, pregnancy
will usually proceed to term without difficulty. If, on the other hand,
these tumors are larger and impinge upon the uterine cavity, the cir¬
culatory disturbances with which they are associated will frequently
lead to a placental hemorrhage and thus to premature expulsion of
the ovisac. It would also seem that in the presence of these tumors
there is increased irritability of the uterine muscle. Verrucoli be¬
lieves that the abortion in cases of myoma is due less to mechanical

ETIOLOGY OF SPONTANEOUS ABORTION

109

Fig. 32. — Retroverted pregnant uterus. The left-hand figure shows conditions at the end of two months when it is usually possible
to correct the position by manual replacement. The right-hand figure demonstrates the anatomic relations in a four months’ pregnant
incarcerated retroversion of the uterus, with greatly dilated bladder, and threatened abortion.

110

ABORTION

interference than to death of the fetus resulting1 from circulatory
disturbances that interfere with proper nutrition.

Of other pelvic tumors occasionally responsible for abortion men¬
tion should be made particularly of ovarian cysts, especially those
that are impacted in the pelvis by old adhesions and thus produce
abnormal pressure against the cervix during pregnancy. However,
conception is infrequent where adhesions are present.

(5) General Diseases. — Though it is always difficult to ascribe with
any degree of certainty a general disease of the mother, such as in¬
testinal, urinary, or cardiac, as the sole etiological factor in abortion,
clinical evidence would point to such a relationship in certain instances.

Urinary fistulae are often attended by abortion, if pregnancy oc¬
curs, Kroner found that in 23 out of 36 such cases the fetus was expelled
before viability. Doubtless in many instances this is due to an asso¬
ciated urinary infection with bladder tenesmus. Bladder calcidi, on
the other hand, do not ordinarily bring on an abortion. Trettenero
cites a case in which a bladder polyp, producing a severe vesical
hemorrhage, was responsible for abortion. Of special interest are the
observations of Guy Hunner who found a tendency to repeated abor¬
tion in cases of ureteral stricture. These abortions occurred for the
most part in the middle of pregnancy and were usually associated
with some degree of pyelitis. In three instances, after dilating the
strictured area in the ureter, the patients were enabled to carry sub¬
sequent pregnancies without difficulty for the full nine months. It
seems more than likely that in all such lesions of the lower urinary
tract the immediate causative factor of the abortion is a ureteral or
Madder colic brought on by these pathological conditions.

Intestinal conditions, such as obstruction of the bowels, or acute
appendicitis, which are attended by marked peristalsis, tend as a rule
to bring on abortion if the mother is pregnant at the time. This is
less likely to occur, however, if the patient is immediately operated upon
and sedatives given. If the appendix lies over the brim of the pelvis
and hence close to the uterus, interruption of the pregnancy is the rule.
In chronic catarrhal appendicitis there is usually little disturbance of
the uterus and even the removal of the appendix is not ordinarily
attended by abortion.

Diseases of the liver and gall bladder may occasionally be an etiologi¬
cal factor. In cholelithiasis, especially if there is an attack of colic,
infection of the gall bladder or marked icterus, the continuation of
the pregnancy is seriously threatened. In some of these cases the

ETIOLOGY OF SPONTANEOUS ABORTION

111

hyperpyrexia is probably responsible for the abortion. In cases of
icterus it is probable that the cliolemia brings on uterine contractions
and thus leads to a dislodgment of the ovum.

Jaschke, who analyzed 1,548 pregnancies associated with valvular
disease of the heart, found that in only 4 per cent did a spontaneous
abortion occur. In cases with marked decompensation, however, the
resulting cyanosis often led to an interruption of the pregnancy. This
is more likely to occur in multiparae than in primiparae. Bronchial
asthma may lead to repeated abortion after asthmatic attacks (Kamier).

Diabetes , in former years, was rarely associated with pregnancy be¬
cause of the resulting sterility of such patients. Niirnberger states
that pregnancy occurs in only about 5 per cent of diabetic women.
In the last decade this percentage, owing to improved treatment, is
probably considerably greater. Nevertheless, the percentage of these
pregnancies that end in abortion is very great. Offergeld places it
as high as 50 per cent. All diabetic pregnant women must be under
constant close supervision of their diet, with the addition of insulin
as indicated, to avoid such a termination of their pregnancy.

(6) Chemical and Physical Agencies. — Of the chemical poisons pro¬
ductive of abortion the most common is lead. The French Department
of Labor in 1905 found that 609 out of 1,000 pregnancies in lead
workers resulted in abortion. Benson found in such cases traces of
lead in the kidney and liver of the stillborn infants. Blair Bell found
definite evidences of a destructive process due to lead in the epithelial
lining of the chorionic villi of such abortion ova. It was in fact the
basis for his interesting clinical and experimental work upon cancer,
since he felt that if lead had such a specific effect upon the embryonal
trophoblast it might similarly have destructive properties upon em¬
bryonal tumors such as cancer.

The deleterious effect of alcohol upon ovum and spermatozoon has
been generally recognized and it seems likely that even the impreg¬
nated ovum is unfavorably affected if the mother is a chronic alco¬
holic. How much of this is a direct chemical effect and how much
due to associated renal conditions is a difficult matter to gauge.

Nicotine , if absorbed in large quantities by workers in tobacco
factories, may tend to abortion but it is most improbable that cigaret
smoking even to excess can lead to such an event.

Since anesthetics are so frequently employed at the present time in
various operative procedures upon pregnant women the question of
their abortifacient. properties demands careful consideration. Accord-

112

ABORTION

ing to Davis, chloroform is the most dangerous anesthetic for the
fetus, destroying it through excessive injury to the liver cells. Ob¬
jection is also raised by him to the prolonged use of nitrous oxide
anesthesia.

In his monograph “Die Fruchtabtreibung durch Gifte und andere
Mittel, r’ Lewin has collected a vast literature dealing with inorganic
poisons, organic products, and vegetable and animal substances hav¬
ing poisonous qualities that lead to abortion. In most instances these
substances are intentionally taken by women to cause interruption
of pregnancy. In the chapter dealing with “Methods and Accidents
of Illegal Abortion’7 more details will be found. Here it should only
be stated that such poisons may at times be ingested unintentionally
with food, and occasionally drugs having abortifacient properties may
be prescribed by mistake in quantities sufficient to bring on uterine
contractions. This effect may be unavoidable, as in the intensive
treatment of severe malaria with quinine. Nevertheless, very few,
if any, of these substances are sufficiently powerful, even though clas¬
sified as ecbolics, to bring about an abortion. In the second three
months of pregnancy such drugs are more apt to produce an effect
than in the first three months. In case of abortion, other predisposing
factors are usually present.

Concerning physical agencies tending to produce an abortion, only
electricity and irradiation need to be mentioned. A stroke of light¬
ning or a powerful electric shock may lead to sudden fetal death or
to the production of uterine contractions. Cases of this kind are ex¬
tremely rare.

Irradiation of the pregnant uterus has been proved to have such a
uniformly destructive effect upon the developing ovum that it has
been recommended as a non-operative means for therapeutic abortion.
Details concerning the dose employed and manner of application for
this purpose may be found in Chapter XX. Occasionally, however, it
has been employed in cases of pregnancy wrongly diagnosed as fibroid
uterus, or in a combination of these two conditions. The positive
exclusion of such a pregnancy by means of the Aschheim-Zondek test
is therefore, very important. This is doubly true because in the event
of a pregnancy treated by large doses of x-ray or radium, if abortion
does not occur, the child at term will be found to be either deformed
or mentally defective in a very large proportion of instances. These
harmful effects of irradiation upon the ovum as shown by Douglas
Murphy are limited almost wholly to the large therapeutic applica-

ETIOLOGY OF SPONTANEOUS ABORTION

113

tions directly to the pelvic organs. Where x-ray treatment has been
applied to a leucemic spleen and the pelvic organs have been carefully
protected from any radiation effect, the pregnancy may proceed with
the delivery of a perfectly normal, healthy child developing no harm¬
ful after-effects, as in a case recently observed by me. X-ray used
briefly for purposes of diagnosis either in a radioscopic or radiographic
manner produce no deleterious effects. Even if such examinations
have to be repeated a number of times, abortion is usually not pro¬
duced, nor harmful effects upon the ovum noted later.

Radium treatment for fibroids of the uterus is occasionally followed
by a pregnancy. Linton, Marks and Smith found that out of 250
women, so treated, 13 subsequently became pregnant, and that out
of 20 pregnancies in these 13 women, only 3 were terminated by
abortion.

(7) Operative Procedures. — While all operations that can be post¬
poned until the termination of the pregnancy should, as a rule, be
delayed, it may become necessary to proceed actively in the treatment
of certain complications. The more common of these are acute ap¬
pendicitis, ovarian cysts with twisted pedicle, pedunculated adherent
fibroids of the uterus, intestinal obstruction, and abscesses in various
organs. Particularly if a pelvic tumor is located in the cul-de-sac or
near the pelvic brim where it is likely to become a factor in complicat¬
ing the delivery of the child at term, it is advisable to remove such a
tumor relatively early in the pregnancy. The nearer the field of op¬
eration is to the uterus, and the more the case is complicated by fever,
extreme pain and toxemia, the more likely is the pregnancy to be
interrupted by the operation.

It is surprising, however, how well the pregnant uterus will tolerate
removal of even fairly large myomatous tumors without abortion,
particularly if the operator employs extreme gentleness in his maneu¬
vers, and follows the operation with considerable doses of opiates
over several days. Hemorroidal operations and operations on the
external genitals are more apt to arouse uterine contractions than
many major abdominal procedures. Owing to the frequency with
which women during pregnancy have teeth that are decayed or in¬
fected, the question of whether and when to extract such teeth, often
comes up for decision. My advise in these cases has been to delay
extraction until at least the 4th month of gestation if this is at all
possible, especially if it be a molar tooth and the extraction not a
simple one. In most instances I have advised short gas anesthesia in
place of cocainization in order to minimize the psychic shock to the

314

ABORTION

patient. I am quite convinced of the desirability of removing all such
infected teeth in view of the dangers, already mentioned, of focal
infection as a factor in habitual abortion.

B. SECONDARY OR EXCITING CAUSES

(1) Physical Trauma. — The frequency with which external injury
or strain has been held responsible for the production of the abortion
has already been mentioned. That it is often an important contribut¬
ing factor in the initiation of uterine contractions cannot be gainsaid.
But in most instances a careful analysis will show other more funda¬
mental causes. One may well be skeptical of the effect of even rather
violent external trauma in the production of abortion, since we have
so many instances in which internal manipulations, such as curette-
ment, have failed to bring on an abortion. Litzenberg cites as an
example of this, a case in which he once removed a very large, bone
hairpin from a three-months pregnant uterus by vaginal hysterotomy,
with no disturbance of the gestation. In discussing this subject, Seitz
found that the greatest tendency for traumatic interruption of preg¬
nancy was in the first 16 weeks, even though at this time the uterus
lay more protected in the pelvic cavity than later. Direct uterine or
penetrating injury is rare. More often it is due to a sudden jar, to
sudden increased intra-abdominal pressure, or to psychic trauma.
Long, rough automobile rides, especially on motorcycles or side-cars,
are productive of abortion in many instances.

Since the question of accident insurance is often raised in connec¬
tion with alleged traumatic abortions a careful analysis of all possi¬
ble factors must be made in every instance. If any of the fundamental
causes mentioned in the preceding pages are present, the accident
cannot positively be held responsible for the abortion. At times abor¬
tion may have been induced and the accident then claimed as a
subterfuge in order to collect insurance. The presence of fever and
ruptured membranes point to instrumental interference. The time
relation between the accident and the abortion is also to be noted.
If bleeding or rupture of membranes immediately follow the accident
the connection between the two seems probable. In most accident
cases reported by Zweifel the ovisac was promptly expelled.

Sexual intercourse is probably one of the most positive direct trau¬
matic agents productive of abortion. Even Hippocrates called atten¬
tion to this. Menge gives as evidence of the relation between coitus
and abortion, the fact that in many instances habitual abortion may

ETIOLOGY OF SPONTANEOUS ABORTION

115

be overcome only by the strict prohibition of sexual relations during
pregnancy. That abortion should occur with greater frequency where
the uterus is retroverted can readily be understood by a consideration
of the anatomical factors of coitus under these circumstances. It is
also possible, as A. Mayer points out from experimental investigation,
that repeated sexual relations may disturb the normal metabolism
between the corpus luteum and the implanted ovum. Nevertheless
repeated forceful coitus with full orgasm is reported without disturb¬
ing effects (Dickinson).

Since there is a physiological connection between the act of nursing
and the production of uterine contractions as is normally noted after
delivery when the child is put at the breast, it happens at times that
when a nursing mother becomes pregnant, the act of nursing will
incite uterine contractions and lead to a loosening of the ovum from
its uterine attachment.

(2) Thermic Irritation. — Occasionally heat or cold may be a direct
exciting cause of the abortion, as it is well known that extremes of
temperature applied over the lower abdomen will stimulate the uterine
muscle to contraction. This is daily used as a means for controlling
excessive uterine bleeding. In many instances of delayed menstrua¬
tion the application of a hot foot bath or hot sitz-bath or hot water
bottle to the lower abdomen is employed to bring on the flow of blood.
Doubtless often the bleeding is not a delayed menstruation but
an early abortion. Where a pregnancy is not desired by the mother
this method of thermic irritation is frequently helpful. On the other
hand, taking prolonged hot, vaginal douches, may sometimes unin¬
tentionally interrupt a pregnancy. Such accidents are more apt to
occur where menstruation is at irregular or long intervals so that the
patient is not conscious of the fact that she might be pregnant.

(3) Psychic Trauma. — Psychic shock is perhaps more often respon¬
sible for abortion than direct physical injury. Such is the opinion of
Seitz and other writers who speak of the frequency of abortion fol¬
lowing earthquake, flood, severe fires or the terrors of war. Davis
explains this effect of fear upon the pregnant mother as similar to the
well-known incontinence of urine and feces under conditions of ex¬
treme fright. Bouvocque stated that after the explosion of a powder
mill in Grenelle he was called to see 92 women either aborting or
threatened with abortion. During the siege of Strassburg, in 1870,
many women, who sought refuge in cellars, aborted. Naturally the
effect of psychic trauma will depend largely upon the nervous con¬
stitution of the mother. Sensitive women with low blood pressure,

116

ABORTION

who faint under slight provocation, will be more apt to be easily
frightened and to have an abortion result therefrom.

In conclusion then, after this rather lengthy array of possible fac¬
tors in the etiology of abortion, we must confess that our knowledge
of this subject is perhaps inversely proportionate to the number of
factors that have been mentioned. If, however, the next thirty years
show as much increment in the way of information and progress in
prevention as the past thirty years have done, we shall be appreciably
nearer a solution of the problems that now face us.

CHAPTER VII

PREVENTION OF ABORTION

HHE PREVENTION OF ABORTION must naturally be the corol-
* lary to the preceding’ chapter, in which we studied causes. In
many ways it is the most important chapter in this volume since it
presents the various ways and means at present available to bring about
a cessation of those processes that prevent the successful carrying of a
pregnancy to term. How much human happiness is involved in the
saving of these fetal lives ! What greater triumph than to bring to pass
the birth of a living child by a mother who for years has had her hopes
thwarted by habitual abortions! Unfortunately, as the review of our
meagre knowledge concerning the causes of abortion shows, the means at
hand for prevention frequently fail. Nevertheless, the practitioner is
many times himself to blame for failing to utilize even such aids as are
now known.

While we find in some texts a tendency to make a special category
of “ habitual abortion,” it does not seem to me that the distinction adds
anything to our understanding. Certain factors, to be sure, particu¬
larly those that produce primary death of the ovum, such as endocrine
disturbances, defective germ-plasm or dietary insufficiencies, have a
tendency to cause repeated abortion; while others, less fundamental,
especially those due to external irritation, may not occur in subsequent
pregnancies. As it is difficult to draw a sharp line between these fac¬
tors, I have preferred not to make “habitual abortion” a special topic.

The prophylactic care of abortion can be considered under three
heads :

(1) Treatment of the cause before conception

(2) Treatment of the cause during pregnancy

(3) Treatment to prevent uterine contractions

Prophylaxis Before Conception

Either husband or wife, or both, may be a factor in the etiology of
abortion, and preventive treatment must therefore include both if ab¬
normal conditions are present. In the husband, it is usual for the ab¬
normalities to be of such a character as to make conception difficult or
impossible. If, however, an abortion has already occurred, and the
semen of the husband is found to contain evidence of infection, it is
important that he receive the necessary local treatment to cure it. Endo-

117

118

ABORTION

crine treatment, such as anterior pituitary products and theelin, have
also been known to have a favorable effect on less virile spermatozoa.
Quite empirically it may be advisable at times, where the husband’s
basal metabolism is low, to give thyroid gland in small doses to insure the
better condition of the male germinal cells. Dietary treatment, especially
that directed to increase the amount of vitamin E, is worthy of trial.
In any case, wherever our study indicates that the abortion may be due
to defects of the germ-plasm, we must bear in mind that these may be
inherent in the spermatozoon as well as in the ovum. Finally, where
we have evidence of a syphilitic factor, treatment of the husband is
equally important with treatment of the wife, since it is claimed that
the infectious organism may be carried by the male sperm; and in any
case, infection is always possible.

In the treatment of the woman who has aborted, efforts to prevent
further abortions should be first directed to the correction of possible
factors in the genital tract. Relaxation of the pelvic floor with prolapse,
may demand correction. Deep lacerations of the cervix, even though
they may be expected to recur in subsequent labors, will at times re¬
quire operative correction. Hyperplasia of the endometrium may re¬
quire curettage. Retroversion of the uterus, especially if associated with
pelvic adhesions, not sufficient to prevent conception but enough to
interfere with the proper development and elevation of the uterus,
should be corrected, either by breaking up adhesions and inserting a
pessary, or by operative shortening of the round ligaments. In the case
of a bicornuate or arcuate uterus with a septum, it may be necessary
to cut the septum in order to provide room for the growth of the ovum.
In some cases of uterine myoma and ovarian cyst, the removal of the
tumor may be required. Since all these abnormalities of the genital
tract have been occasionally associated with pregnancies carried to full
term, it becomes extremely difficult to select those cases in which we can
be sufficiently certain to warrant operating for this reason alone. Only
where an abortion has occurred more than once are we justified in
definitely insisting on such operations.

Local treatments of one sort or another to improve the condition of
the pelvic organs may at times be necessary. In the case of an infantile
uterus, benefit has been reported from cervical dilation with the intro¬
duction for two or three weeks of an intrauterine stem pessary. In the
presence of ureteral stricture as a possible factor in abortion, we may
follow Hunner’s suggestion to dilate such strictures. In chronic para¬
metritis hot douches and glycerine tampons may prove helpful. Endo¬
crine treatment preliminary to conception has been recommended espe¬
cially in women with low fertility due to a low ovarian function.
Stimulating treatment with vaginal application of radium up to 850

PREVENTION OF ABORTION

119

to 400 mg. hr. has, in my experience, been followed in this type of pa¬
tient by regular menstruation, and in many cases by a conception that
was carried to term. The same result may be obtained by carefully ad¬
ministered suitable doses of x-ray. If the lowered ovarian function is
associated with a hypothyroid condition, the patient should receive thy¬
roid extract, grains one to three daily, for the month preceding the de¬
sired conception. It is also important, where there is excessive activity
of the thyroid gland, to give iodine in increasing amounts for a short
period preceding the desired conception. If the removal of the thyroid
gland is at all indicated, this should preferably be done before another
conception has occurred. Some of this preliminary endocrine therapy
will fail to accomplish its purpose because of the uncertain fertility of
patients of this kind.

A valuable addition to our therapy has come through the evidence
that focal infection elsewhere may lead to an infection of the placental
site with resulting abortion. The elimination of such possible foci about
the teeth, the nasal sinuses, the throat or the abdominal viscera, becomes
a matter of importance where there are repeated abortions in the early
months without other apparent cause. The clinical experiences of Curtis
and others amply justify such preliminary treatment.

Active treatment of syphilis in the mother should be given preferably
before conception has occurred, even though it be continued during the
pregnancy.

Prophylaxis During Pregnancy

Local treatment of the pelvic organs during pregnancy is necessarily
limited by the fact that in sensitive individuals any manipulations are
apt to arouse uterine contractions, and hence induce the very condition
we are anxious to prevent. This applies particularly to the correction
of the introverted uterus (Fig. 33). Plass states his belief that since
in the vast majority of cases such a retroversion is corrected spon¬
taneously, attempted reposition is more likely to disturb the pregnancy
than leaving it alone. My own experiences have not corroborated this
viewpoint. While frequently abortion may result from forcible at¬
tempts to bring the uterus forward, I am convinced that if manipula¬
tions be made gently, no harm will be done, and the tendency to in¬
creased abortion which unquestionably exists in the retroverted uterus
will be lowered. Where gentle bimanual manipulation in the Trendelen¬
burg or knee-chest position fails to correct the retroversion, I usually
employ a rubber bag filled with one to one and a half pounds of mer¬
cury placed in the vagina (Fig. 34) with the patient in the elevated
hip posture for twenty minutes at a time, in order gently to lift the
uterus out of the pelvis (Fig. 35). If treatments are given at intervals

120

ABORTION

of two or three days, and the patient is given opiates and instructed
to rest the entire day after treatment, I have never seen any harmful
results. Within two or three weeks, the uterus can be replaced, and
can be held forward by a pessary until after the fourteenth week of
gestation, when it will remain in position without support.

No method of treatment for the prevention of abortion has been at¬
tended with as much success as that of endocrine therapy. Particularly

Fig-. 33. — Prevention of abortion by replacing- the retroverted gravid uterus. The
upper diagram illustrates the knee-chest posture and the lower figure shows a pessary
inserted with the patient in this position to keep the uterus forward.

in repeated abortion do we find that corpus luteum, given by mouth, or
preferably intravenously or intramuscularly, has yielded satisfactory
results. Weinzierl orders six to eight tablets of luteo-glandol daily, ac¬
companied by two or three hypodermic injections a week. His six cases,
all of whom had previously aborted, went to full term without any ad¬
ditional precautions as to rest. He believes that the lutein extract has a
specific effect on the ovum and a sedative effect on the uterus. Even

PREVENTION OP ABORTION

121

where the bleeding has already begun and the abortion is threatened,
Wolfsohn has successfully employed lutein extract (luteogan) in daily
injections intramuscularly, with cessation of bleeding and a success¬
ful termination of the pregnancy in seven out of ten cases.

In American literature we also find many favorable reports with the
use of lutein extracts. Krohn, Falls, and Lachner advocate the con¬
tinued use of corpus luteum extract preparations during pregnancy
in cases of habitual or threatened abortion. They continue its em¬
ployment until death of the fetus has been established. In fourteen

Fig". 34. — Instruments for mercury weight treatment, consisting of a colpeurynter, a
flask containing two pounds of mercury, a funnel, and dressing forceps.

out of nineteen cases they were successful. These nineteen patients
had had forty-eight previous pregnancies, 69 per cent of which had
terminated in abortions.

My personal experience with this form of treatment has been most
satisfactory. In one patient who had been pregnant four times, spon¬
taneous abortion occurred twice where no lutein had been given, while
in the two pregnancies in which lutein therapy was carried out con¬
sistently, the child was carried to term. While we are justified in
a certain amount of skepticism regarding the therapeutic value of
substances concerning which we know as little as we do concerning

122

ABORTION

corpus luteum extract, the clinical experience of many men in many
countries justifies the assumption that the giving of this extract,
especially in the intravenous form during pregnancy, has definite value.
In view of the small number of therapeutic measures available, this one
should be employed in every case of ‘ ‘ habitual abortion. 7 7

Other endocrine extracts seem less effective. Theelin, the follicular
hormone of the ovary, seems actually slightly to predispose to abortion,
and in view of the fact that it is excreted in large amounts in earlv
pregnancy, cannot be required by the embryo and hence is of no value.

Fig. 35. — Mei’cury weight pressure treatment for replacing the retroverted gravid
uterus. The patient lies in the elevated hip position for twenty minutes, with the
bag filled with mercury, pressing against the posterior vaginal fornix. Insert shows
anatomic relations before introduction of bag.

Placental extracts as recommended by De Snoo and H. H. Schmid act
similarly to corpus luteum. Schmid reports two cases where powdered
placenta was given with good results in “ habitual abortion. 77 De Snoo
gives three grains daily of placental extract, especially in cases of more
advanced pregnancy (fourth to sixth month), with the idea that it de¬
creases irritability of the uterus. In cases of marked hypothy¬
roidism, especially if associated with loss of hair and general weakness,
thyroid in increasing doses may prevent an abortion. In other instances,
iodine will be employed with favorable results. In fact, iodine in the

PREVENTION OF ABORTION

123

form of potassium iodide was the favorite remedy for the prevention
of abortion for over thirty years between 1880 and 1910. The favor¬
able effect of these iodides was formerly explained as due to the cure
of a latent syphilis, but in most instances the effect is more likely to be
attributable to its influence upon the endocrine secretions and body
metabolism.

An interesting suggestion made by Sellheim, and corroborated by the
clinical experiences of other German gynecologists, is the administra¬
tion of the serum of other normal pregnant women to those having a
tendency to abortion. Cases of habitual abortion have been successfully
treated in this way abroad.

Sellheim injected 10 c.c. of the blood serum of normally pregnant
women with negative Wassermann reaction, intramuscularly every 14
days throughout the pregnancy. The blood was not always taken
from the same patient and several times the injections were not con¬
tinued in the later months. He believes a smaller dosage may be
equally effective.

(1) The influence of the growth stimulating hormone upon the vital¬
ity of the chorionic villi.

(2) The effect of the serum upon fetal metabolism.

(3) The fact that it may combine with harmful toxins that wrould
otherwise produce fetal death.

(4) The fact that it favors increased growth of the uterus, and de¬
creased irritability of the uterine muscle.

In connection with the possible effect of such pregnancy serum upon
harmful toxins, mention should be made of the favorable results obtained
by Vignes in cases of focal infection due to streptococci by the use of
a specific streptococcus vaccine. In one case four previous abortions
had occurred, and the streptococci were found under the gums of the
patient. Twelve injections of an autogenous vaccine, made from these
streptococci, were given, and the pregnancy was carried to term.

Finally, the diet of the expectant mother demands careful attention.
Tt should preferably be salt free or salt low, should include ample cal¬
cium supply and be rich in vitamins, especially B and E. Vitamin B
may be given as viosterol, ten drops two or three times daily; and vi¬
tamin E in the form of whole wheat bread, eggs, cream, custard, etc.
Vogt-Moeller strongly recommends giving wheat-germ oil containing
large quantities of vitamin E in the form of a proprietary preparation
called Fertilan. Unfortunately, the preparation of most of these vitamin
products is so imperfectly developed that we can as yet make no definite
recommendations of any concentrated extracts, but must largely depend
upon dietary measures.

The interesting observations of E. C. P. Williams on carbohydrate

124

ABORTION

metabolism have already been mentioned in the previous chapter. In
such cases, where abortion is apparently due to lowered sugar tolerance,
the following treatment is instituted : 150 to 300 gm. of carbohydrates
are given daily, but in six small instead of three large meals. Insulin
was added to this limited diet in two cases, with favorable results in
the majority of pregnant women.

To Prevent Uterine Contractions

Since the cause of a previous abortion cannot be determined with any
degree of accuracy in more than half the cases, and since in a very con¬
siderable number the threatened abortion arises in the first pregnancy
of the individual without any clues as to a possible cause, preventive
measures must, in this group, consist largely of efforts to head off uterine
contractions, or to arrest them if they have already begun.

Our success in these measures will depend to a considerable degree,
first upon the underlying sensitiveness of the uterine muscle to various
forms of irritation, and in the second instance on the co-operation of
the patient in carrying out measures that will prevent the onset or per¬
sistence of uterine contractions. Mention has been made of the varying
degrees of sensitiveness among women to trauma and pelvic manipula¬
tion. Cases are on record where patients have been subjected to intra¬
uterine procedures such as the introduction of a catheter, curettement,
etc., and nevertheless have carried the pregnancy to full term. In
several instances, the catheter or other foreign body introduced into the
uterus remained until the onset of labor and was expelled with the child;
while in other individuals, the gentlest of pelvic examinations may bring
on uterine contractions and abortion.

The co-operation of the patient in the prophylactic treatment is of
greatest importance. Many times the patient is unwilling to be sub¬
jected to the absolute rest in bed necessary to prevent a miscarriage,
owing to the fact that she is not particularly anxious to have more
children. In other instances the social and economic conditions in the
home may be such as to make it impossible for her to give up her family
occupations such as cooking or care of children; or, in the case of the
actual onset of bleeding, to go to a hospital, where absolute rest in bed
may be assured. In many instances it will require great tact on the part
of the physician, and patience on the part of the expectant mother, to
bring the pregnancy to a successful termination. The physician often¬
times will be unjustly criticized in those cases where in spite of prolonged
rest in bed, the abortion has nevertheless occurred. Such unjust criti¬
cism every physician must face from time to time, and notwithstanding
will do his utmost to carry out the measures necessary to save the life of
the child “in utero,” even though the mother is lukewarm in her desire

PREVENTION OF ABORTION

125

for further offspring. The physician should, of course, familiarize him¬
self with the symptoms and findings of inevitable abortion, more par¬
ticularly with those cases of fetal death giving a negative pregnancy

hormone test, so that the rest treatment need not be carried on unneces¬
sarily when the fetus is dead and the abortion is no longer preventable.

Before the actual onset of contractions or bleeding, which point to
threatened abortion, our efforts should be directed toward the elimination
of all possible irritating factors. Once a diagnosis of pregnancy has been
made, all forms of violent exercise, such as tennis, running, swimming,
or prolonged dancing, must be prohibited. Household obligations should
be limited to the simplest things, with the avoidance of anything that
entails heavy lifting or stretching. Attention to regularity of the bowels
is of great importance so as to avoid straining at stool, which is apt to
loosen the attachment of the ovum. Prolonged automobile rides are in¬
advisable, and in fact any form of travel involves some risks. Sexual
relations are absolutely to be prohibited in women who tend to abort
readily in the first four months, and in certain instances this restric¬
tion should extend throughout the pregnancy.

AVe know from physiological investigations that although, as a rule,
ovulation ceases during pregnancy, the menstrual wave, as manifested
by slightly increased body metabolism and increased nervous irritability,
may persist for several months after conception in certain individuals.
For this reason the measures employed to allay uterine irritability are to
be more strictly enforced at the time of the expected period. I make it a
rule, in cases where the possibility of abortion demands special considera¬
tion, either because of a previous accident of this sort or because of a
preceding sterility, to put the patient to bed for from five to ten days at
the second and third expected menstrual period; at the same time giving
luminal, half grain three times daily, in certain instances, combined with
a quarter or half grain of codein. During this period of prolonged bed
rest, the diet is regulated, with or without the addition of mild laxatives
such as mineral oil, to prevent constipation. The evidence from recent
reports of the sedative value of corpus luteum extracts justifies our giving
this preparation in hypodermic form or intravenously, especially at the
expected menstrual periods.

Even more stringent measures are necessary, if in spite of these in¬
structions, or without previous warning, symptoms of uterine bleeding
or contractions have arisen. In such cases, large doses of opiates should
be given at once in the form of morphine (gr. % to 1/4), repeated in a
half-hour until pains cease or respirations are reduced to fifteen per min¬
ute. Dilaudid (gr. % 2), hypodermically, repeated every two to three
hours for four doses, should effectively control uterine contractions, and
seems to have less tendency to produce constipation than other forms of

126

ABORTION

opiates. The barbiturates in fairly large doses also have an excellent
sedative effect and may be given for a long period of time after the
opiates have quieted uterine contractions. Varo recommends a combi¬
nation of novatropin and papaverin. Graff gives suppositories contain¬
ing extract of belladonna (gr. %) or atropin (%oo gr.), three times
daily.

All medication, however, is of secondary importance to absolute rest
in bed. If the patient remains at home, a bed pan must be employed.
Preferably, such patients should be sent to the hospital where they
can be watched more closely, and hypodermics given whenever needed.
Psychic rest is also of considerable value, and this constitutes another
reason for hospitalizing many patients, especially where the presence of
children or other members of the family may be a source of irritation
at home. It will often be a matter of considerable difficulty to decide how
long such absolute bed rest must be employed, but I prefer to err on
the side of extreme caution, since in many cases where I have tried to
shorten the time of precaution, bleeding and contractions have returned.
If no fresh bleeding has occurred for five days, and only a small quantity
of brownish vaginal discharge is present, I permit the patient to sit up
in bed and in the course of another week, to leave the hospital. Naturally,
we must be guided to a large degree by the particular circumstances of
the case. If the pregnancy has occurred after long years of waiting,
and the possibility of another conception is very dubious, no stone must
be left unturned to carry out the treatment of rest and sedative to the
ultimate degree. In some instances, only by prolonging this rest to the
period of viability, can we hope to be assured of carrying the pregnancy
to a successful conclusion. Patience is rewarded in many of these in¬
stances. Jensen-Carlen reports success in five out of seven cases of
habitual abortion ” with bed rest alone. Van Dongen was able to save
38 per cent of his threatened miscarriages.

In conclusion, therefore, we must avail ourselves of all agencies known
at present for the prevention of abortion, and trust that future investi¬
gations throwing further light upon possible causes will before long
place more effective measures in our hands.

CHAPTER VIII

MECHANISM OF ABORTION

IN CONTRAST to the mechanism of labor at term the Modus Abortus ,
A or method of abortion, presents interesting variations that may be
grouped into the typical one-stage expulsion and the atypical two-stage
expulsion.

One-Stage Abortion

The one-stage type is usually limited to the first twelve weeks of preg¬
nancy. If we will recall the anatomic conditions at this time, the
reason for this will be self-evident. The ovisac at this period has
not as yet developed villous stems that penetrate into the uterine
wall and effect a firm attachment of the embryo to the mother. Par¬
ticularly in the first six weeks, only a layer of decidua rather loosely
glues the ovisac to the uterine mucosa. This decidual layer completely
lines the uterine cavity and separates the mucosa from the fibromuscular
wall. When, therefore, either through fetal death or other spontaneous
causes, uterine contractions are aroused, the separation of the entire
ovisac with the decidual envelope is readily accomplished. Particularly
if preceding these contractions there has occurred liquefaction necrosis
of the decidual layer will the expulsion of an intact ovisac be the usual
mechanism (Fig. 36). At times that portion of the decidua over which
the ovisac lies is first loosened and the blood clot that forms back of it
extrudes it into the uterine cavity. If the parietal layer still partially
clings to the uterine wall, a mechanism may result similar to the expul¬
sion of the placenta by the Schultze method, the ovisac preceding the
passage of the parietal decidua, so that the surface lining the uterine
cavity is outside.

The mechanism of such one-stage abortions is only possible where there
has been no previous intrauterine instrumentation. In the latter event
there is almost always a considerable amount of retained material. Even
in the typical one-stage abortion we not infrequently find a larger or
smaller island of parietal decidua which is subsequently expelled or re¬
moved with the curette.

Two-Stage Abortion

Where pregnancy has advanced beyond the twelfth week, it is ex¬
tremely rare for the ovisac to be expelled, intact. Numberger describes
four varieties of two-stage abortion (Fig. 37) :

127

128

ABORTION

(1) The decidua capsularis tears off from the parietal decidua and
the embryo is expelled in its capsularis sac with subsequent expulsion
of the remaining parietal decidua.

(2) The embryo is expelled intact, covered by its membranes but with
both capsular and parietal decidua remaining in the uterus and expelled
later.

(3) The chorion has also been detached and the embryo is expelled in
its amniotic sac.

Fig-. 36. — One-stage mechanism of abortion. The left-hand drawing shows the
ovum expelled intact in its decidual sac ; the right-hand drawing shows the decidual
sac ruptured and the ovisac extruded with the inverted decidua following it.

(4) The membranes rupture, the embryo is expelled followed later by
the placenta as in delivery at term (Modus Partus).

Concerning these four methods of two-stage abortion, it is noteworthy
that the fourth type in which the fetus is expelled separately, occurs
more often between the twentieth and twenty-eighth week. This mecha¬
nism of abortion is usually followed where there has been instrumental
rupture of the sac and is more common in cases in which inflammatory
changes of the membranes have produced abnormal friability.

MECHANISM OP ABORTION

129

The expulsion of the embryo in its amniotic sac is extremely rare and
happens usually between the twelfth and eighteenth week of gestation
(Fig. 38). In the first form of two-stage abortion the smooth, glistening

surface of the decidua can readily be distinguished from the rough,
shaggy covering that marks the placental site. Where the entire decidua
has been stripped off and left in utero, the expelled ovisac is entirely
covered by such a shaggy surface (Fig. 39). On the whole, the decidual

130

ABORTION

coating is more friable than the other tissues and portions of it are more
apt to break off and be left behind. In most instances these pieces

Fig. 38. Eight weeks’ fetus with unruptured amniotic sac, corresponding to stage

B in Fig. 37.

Flg' 29iT“Fetus ,ancl Placenta of twelve weeks’ development. The fetus after rupture
of the membranes was first expelled but remained attached to its placenta.

of decidual tissue arc expelled spontaneously one or two days after
the abortion has occurred (Fig. 40).

If the entire ovisac is expelled spontaneously in one or two stages, we
apply the term complete abortion. If, on the other hand, portions of

Chorionic Villi

Chorion laeve

Embryo

1 Umbilical cord

Amnion

MECHANISM OP ABORTION

131

the embryo, the placenta or decidua remain in the uterus, the term in¬
complete abortion is used. In the stage in which contractions and bleed¬
ing have started but the ovisac has not yet been detached, we apply the
term threatened abortion. If such a detachment of the ovisac has reached
a stage where nothing can prevent its expulsion, we refer to it as in¬
evitable abortion.

Fig'. 4 0. — Intact uterine cast of decidua, expelled subsequent to the fetus and placenta

from same case (Fig'. 39).

Cervical Abortion

Among the more uncommon forms of abortion is that in which the
mechanism of expulsion of the ovisac meets with such resistance at the
external os of the cervix that although the ovum has been completely

132

ABORTION

detached from its site in the body of the uterus, it remains lodged in the
cervical canal for a considerable time (Fig. 41). A few factors that
predispose to such cervical retention might be mentioned : low amputa¬
tion of the cervix, radium stenosis of the cervix, cautery stenosis, and
agglutination or partial atresia of the cervix. Bacialli reported a case
of two months’ gestation in which the cervix was ballooned out by the

Fig-. 41. — Cervical abortion. To the left, the uterus with ovum lying loosely at¬
tached in the dilated cervical canal ; to the right, the ovum opened up after ex¬
pulsion to show the small embryo within its amniotic cavity.

ovisac with the fundus of the uterus riding above it like a cap. In this
case there was free hemorrhage so that the cervix had to be cut to per¬
mit the extraction of the ovisac. In the case described by Masieri a
cervical abortion occurred at the third month followed in three months
by another pregnancy in which a similar lodging of the ovisac in the
cervix occurred. The absence of contraction pains and the frequency

MECHANISM OV ABORTION

133

of rather free bleeding is characteristic of this mechanism of abortion.
It is possible that in some of these cases the development of the placental
site may have been near the internal os. But the rarity of a decidual
reaction in the cervix makes it improbable that we are here dealing with
a primary attachment of the ovisac in the cervical canal. Furthermore,
examination of the expelled ovisac reveals usually a fibrinous coating
indicating that the ovum has been detached from the maternal circula¬
tion for some period of time.

Fig-. 42. — Abortion through cervico-vaginal fistula. Notice the thick, tightly closed,
cervical canal, and the thinned-out ruptured posterior wall of the cervix with ovisac
protruding.

Abortion Through Cervico-Vaginal Fistula

As an occasional termination of abortion Ileynemann calls attention
to a mechanism in which, with a tightly closed cervical canal the ovisac
is forced through the thinned out cervico-vaginal junction, thereby creat-

134

ABORTION

ing after its expulsion a cervico-vaginal fistula (Fig. 42). Vonnegut in
analyzing three cases with this type of mechanism was of the opinion that
previous instrumentation, or attempts at instrumental abortion, had
weakened the cervical wall and created a false passage so that the ovi¬
sac was expelled more readily through this passage than through the
cervical canal. He states that such fistulae occur almost exclusively in
primiparae after the third or fourth month. Caffier (four cases) also
states that these fistulae almost invariably are preceded by criminal
punctures or ill-advised efforts to dilate the cervical canal. The spon¬
taneous expulsion of a five and one-half month fetus through the
posterior wall of the cervix into the vagina is described by Silin who
attributes it to an abnormally rigid cervix. In the summary of thirteen
cases in literature reported by Bublitschenko only three had previ¬
ously had children. He believes that where there has been no instru¬
mentation this accident may occur as a result of extreme anteflexion
of the pregnant uterus with anatomical thinning of the upper part
of the cervical canal.

Vaginal Abortion

In extremely rare instances we may find a stenosis of the vagina that,
similarly to the mechanism of cervical abortion prevents the expulsion of
the ovisac, although it is lying in the upper vaginal canal completely
extruded from the uterus. A tendency to rather extreme hemorrhage has
been noted in the few cases on record of this method of expulsion.

Concerning the mechanical factors that enter into the prolonged reten¬
tion of the ovisac, as in missed abortion and mole pregnancy, we refer
the reader to Chapters XVI and XVII, where this subject is considered
in greater detail. In general we may say that the normal physiological
reactions in the form of rhythmical contractions of the uterine muscle
are as characteristic in abortion as they are in full term labor. These
colic-like pains of uterine contraction are limited to the period in which
the foreign body (ovisac) is still within the uterine cavity. Once it
has been expelled into the vaginal canal the painful contractions cease,
provided the mass of the ovisac is not too large. We thus find in abor¬
tion of the first three months, even though the ovisac is not expelled from
the vagina, that the cessation of uterine contractions indicates that in
all probability the ovisac has been completely expelled from the uterine
cavity.

CHAPTER IX

SYMPTOMS AND SIGNS OF ABORTION

DRECEDING THE SYMPTOMS produced by the abortion, we find
* practically without exception some evidence of the pregnancy itself.
These symptoms consist of absence of menstruation for a greater or less
period of time, nausea and vomiting, fullness and tenderness of the
breasts, and increased frequency of urination. Any or all of these
symptoms may, however, be lacking at times, so that the patient does
not even suspect the occurrence of a pregnancy at the time when the
abortion has already begun. Two conditions are particularly likely to
lead to such mistakes. One is that in which the presence of myomata
in the uterus has led to a persistence of a menstrual -like bleeding in
the early pregnant uterus. The other occurs in patients who have been
in the habit of menstruating with great irregularity at intervals of from
six weeks to four or five months and who have therefore paid little atten¬
tion to a renewed period of amenorrhea and have interpreted the return
of clotted vaginal bleeding with cramps as an abnormal painful men¬
struation until the expulsion of the ovisac has demonstrated their mis¬
take.

Usually the symptoms of pregnancy will pursue their normal course,
with typical changes as the pregnancy advances. Where, however, there
has occurred relatively early a sudden complete cessation of the nausea,
or where in later months the fullness of the breasts shows a definite
subsidence associated with an absence of enlargement of the uterus and
the lower abdomen, we may seriously suspect, even in the absence of
the active symptoms of abortion (bleeding and contractions) that some¬
thing has happened to the ovum to produce fetal death.

As a rule, the first symptom of an impending abortion is experienced
by the patient as a rather pronounced backache, or colicky cramps
in the lower abdomen. Particularly in primigravidae should the occur¬
rence of a persistent backache in the first two or three months of preg¬
nancy, if not explainable on other grounds, arouse suspicion of an
impending abortion. Associated with this backache we occasionally find
an increased amount of mucous discharge, even before the appearance
of any bloody tinge. Then within a period of time varying from a few
hours to several days there may occur a bloody vaginal discharge usually
bright red at its outset with a few clots that enable one to distinguish it
fairly readily from a menstrual flow.

135

136

ABORTION

At other times bleeding may be the first symptom. The patient may
wake np in the middle of the night without any feeling of discomfort
in the back or abdomen but with a free bright red vaginal bleeding as
evidence of the disturbed gestation.

The severity of the pains and the amount of the bleeding vary greatly
in the individual case. In some women the pains are so slight that they
pay but little attention to them and proceed with their daily routine un¬
til the abortion has occurred. At other times the pains may be so severe
that the patient declares that it was worse than having a baby. Naturally,
the more advanced the pregnancy, the greater the dilatation of the
cervix, and consequently the greater the severity of the contractions and
the pain experienced. In the primigravida whose cervix has not before
been subjected to dilatation the pain experienced is more severe than in
the plurigravida.

In the quantity of bleeding and its persistence there is also great
variation. More profuse bleeding is present in the more advanced preg¬
nancies. The character of bleeding varies, depending upon whether or
not there has been a cessation of uterine contractions. From a bright
red color with clots the vaginal discharge gradually changes to a dark
red and finally to a brownish tinged flow. With renewed detachment
of the placental site, this discharge may again assume a bright red
color with increased floiv. Other symptoms such as a dragging sensation
in the pelvis, increased frequency and urgency of urination and a pres¬
sure in the rectum associated with a tendency to constipation may be
present. These rectal symptoms are particularly pronounced if opiates
have been given to retard the progress of the abortion.

In a pregnancy of over ten weeks’ duration the amniotic sac may
rupture with the expulsion of a watery discharge. In a few instances
this symptom associated with a slight tinge of blood may be the first
indication of the abortion and in such cases the abortion is inevitable.
As a rule, the rupture of the amniotic sac occurs only after a considerable
period of uterine contractions associated with pain. The amount of
fluid naturally varies with the stage of development of the pregnancy.
The passage of the fetus following upon the flow of amniotic fluid is
characteristic of abortion where the pregnancy has advanced to four to
six months.

The course of the abortion shows great variation in its duration. At
times the process is completed within an hour regardless of rest and the
giving of sedatives. At other times it may extend over several weeks or
even months before the ovisac is expelled.

Physical Signs. — Examination of the patient with beginning abor¬
tion will usually reveal certain definite changes. By vaginal palpation
the cervix will be found somewhat softened, with the external os as a rule

137

SYMPTOMS AND SIGNS OF ABORTION

showing increased patency, often sufficient to admit the finger tip. At
times a bit of the ovisac can be felt protruding from the uterine cavity
into the cervicai canal. Even where the cervix is closed, however,
other changes will be manifest. The characteristic softening of the lower
uterine segment known as Hegar’s sign will either be absent or markedly
less than the average finding, so that cervix and body of the uterus are
equally and continuously firm in consistency.

•/ ...

WK 'm^< Contraction

rincr

^-'-Interned Os

External Os

Fig-. 43. — Placenta of five months’ g-estation pocketed in the horn of the uterus.

The impression is gained of a lessened angulation or anteflexion of the
uterine body. The body of the uterus will also be altered in consistency.
Its compressibility will be less marked, the contours of the uterus will be
more clearly outlined, its consistency will be somewhat firmer, its shape
more definitely rounded, and its position more erect. At times, in the
process of palpation an increasing hardness, associated with discomfort
or pain by the patient, will give evidence of increased uterine irritability,
with relaxation and contraction noticeable to the fingers in the bimanual

138

ABORTION

examinations. As the expulsion progresses, the physical examination will
reveal greater dilation of the cervix with more or less extrusion of the
ovisac into the vagina. At times the fetus may be felt lying within the
cervix or halfway extruded into the vagina with the uterus riding above
it, still containing the placenta. When the fetus has been expelled and
the placenta retained, the uterus remains large and boggy, somewhat
asymmetrical ( Fig. 43 ) .

The adnexal regions will usually show no abnormal findings, although
in thin-walled women it may be possible to palpate the ovary which has
been enlarged by the corpus luteum of pregnancy.

In abortions occurring from the fourth to the sixth month of gestation,
we occasionally find that, after the complete expulsion of both fetus and
placenta, there may develop on the third day post-abortum, as in full-
term pregnancy, an engorgement of the breasts with an outpouring of
milk-like secretion. This engorgement may be quite painful and last for
several days.

Since the risk of infection is great, even in spontaneous abortion,
physical examinations should be reduced to the minimum. Rectal bi¬
manual palpation will usually suffice to diagnose the condition of the
cervix and the presence of abortion products in the vagina. If vaginal
examination is required, the vulva should be shaved and cleansed and
the hand protected by sterile gloves. The presence of blood clots about
the vulva makes it desirable to shave the vulva and apply sterile pads,
even where no treatment or examination is planned.

CHAPTER X

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

OINCE IRREGULAR menstruation in the form of amenorrhea fol-
^ lowed by a rather free flow of bright red clotted blood is not
uncommon, it is most important to determine whether or not in a given
case the patient is pregnant, so that treatment may be guided accord¬
ingly.

Pregnancy Hormone Test. — In arriving at this diagnosis, we may
now rely not merely upon the history and physical signs, but also upon
the results of the Aschheim- Zondek or Friedman laboratory tests for the
presence of a pregnancy hormone. The factors producing this reaction
and the technique of this test will be found fully explained in textbooks
on obstetrics. With increased perfection of technique the percentage
of error in cases of pregnancy advanced beyond the fifth week of gesta¬
tion is now not over two or three, and it has therefore become one of the
most valuable adjuncts in the diagnosis of pregnancy and so important
that every practitioner should be familiar with it. The main features
of the Friedman test are as follows :

About three to four ounces of a fresh morning specimen of urine of
the patient are brought to the laboratory, and 5 to 10 c.c. of this urine
are injected intravenously into the marginal ear vein of a mature female
rabbit. After thirty-six to forty-eight hours the animal is opened for
examination of the ovaries and in case the patient is pregnant, there
are one or more hemorrhagic follicles or corpora lutea. The urine is
usually filtered and weakly acidified before injecting it into the animal.

The use of a rabbit, first suggested by Friedman, in place of the mice
or rats originally used by Aschheim and Zondek, has the advantage of
greater simplicity and speed. The test is about 98 per cent positive (Fig.
44).

Wheal Test. — A further test worthy of mention in the early diag¬
nosis of pregnancy is the development of wheals, “ quaddel-reaction ’ '
following upon the intracutaneous injection of an isotonic saline solution,
The technique of this test is as follows : 0.2 c.c. of an exact isotonic

normal saline solution is injected intracutaneously in the flexor surfaces
of the lower arm and lower leg. The wheals formed by this injection will
usually remain on an average for an hour. Obladen, who investigated
this test in pregnant women, found that these wheals were absorbed
more readily in pregnant than in normal women. In pregnancy from the

139

140

ABORTION

third month on the wheals disappear in twenty to thirty minutes. In
pregnancy after the second month, the test was positive in 27 of the 31
cases. In the first eight weeks of gestation, however, the test was posh
tive in only 12 out of 18 cases. In 19 patients who aborted the reaction
returned to normal 3 to 4 days after the ovisac was expelled. In two
out of three cases in which the fetus had been expelled but the placenta
retained, the reaction remained positive. (Absorption of the wheal in

Fig\ 44. — Friedman hormone test for the diagnosis of early pregnancy. A shows a
negative reaction ; B, a positive reaction with many hemorrhagic follicles.

thirty minutes.) In 60 controlled cases where no pregnancy existed
there was never any shortening of the absorption time of the wheal.

With a percentage of error amounting to 7 the wheal reaction cannot
replace the hormone reaction of the Aschheim-Zondek test, but may
prove to be a valuable corollary to it. The greater value of the preg¬
nancy hormone test is in the earliness of the answer, right after the first
omitted period. By the time the second period is overpassed, bimanual
examination will elicit the globular, enlarged compressible uterus with
softening of the lower uterine segment, and laboratory tests will usually
not be required to establish the diagnosis of a, pregnancy.

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

141

Another important aid in the early diagnosis of pregnancy is a roent¬
genogram of the pelvis after pneumoperitoneum. Peterson who de-
veloped this method was successful in making the diagnosis uniformly
between the sixth and tenth week of gestation without any disturbance

Fig-. 45. — Roentgenogram after pneumoperitoneum of pelvic organs in a patient two
months pregnant, an aid to early diagnosis. (Courtesy of Dr. Irving C. Stein.)

to the patient from the injected air. The enlargement of the uterus,
especially at a point corresponding to the lower uterine segment, is quite
characteristic. The accompanying illustration (Fig. 45) was made from
a case of Dr. Irving Stein, who has done much to develop the technique
of this procedure. It is positive long before any ossification centers of
the fetus can be visualized.

142

ABORTION

Diagnosis of the Abortion

Granted that the fact of pregnancy has been established with reason¬
able certainty, upon what do we base the diagnosis of an abortion ? First
of all upon the bleeding, irregular as to onset and amount, lasting far
beyond the usual menstrual period, and attended with clots; in the next
place upon the pains, characterized by their rhythmic progression, radiat¬
ing over the lower abdomen to the symphysis. If the patient has been
recumbent for some time, digital examination will reveal the presence of
clots, in greater or less amount, filling the vagina. The cervix will, as
a rule, show some degree of dilation depending upon the stage of abor¬
tion during which the examination is made. It may happen that a
portion of the ovum is palpated at the external os in process of being
expelled. Bimanually, the uterus has no longer the soft consistency of
the pregnant organ, but is cpiite firm, owing to the continued contrac¬
tions. Owing to this hardness the outline of the organ becomes more
distinct. At times, in abortion of the fourth or fifth month, such uterine
contractions can be observed by the examining hand.

Should the question of pregnancy be in doubt, the diagnosis of abortion
becomes much more difficult. We must try to discover the various factors
that might reveal the existence of a gestation. However, this is a matter
of considerable diagnostic difficulty, since during the abortion the physio¬
logical succulence and softness of the pregnant uterus has to some extent
disappeared. There is some diminution in the size of the uterus. In
the second month of gestation the aborting uterus may feel almost as
firm as a normal one.

Where the previous history and the physical examination leave us with¬
out a clue, we can often draw positive conclusions by investigating the
character of the material expelled from the uterus. Unfortunately,
women do not realize the importance of saving such pieces for the in¬
spection of the doctor. Too often we are met with the reply that they
were passed in the toilet or thrown away, as of no consequence, or we
must be guided by the ofttimes very inaccurate description offered by
the patient herself. When the tissue is kept for examination, small
pieces of chorionic membrane are usually readily recognized by their
delicate coral-like character. Often the embryo is not discovered in early
abortions. Not infrequently it undergoes partial or complete liquefac¬
tion. The decidua has usually a somewhat brownish color and is in
layers. The ovisac itself may vary in size from a small vesicle, the
size of an acorn, to a mass as large as a grapefruit.

Microscopically, the diagnosis of a preceding pregnancy, and hence of
an abortion, may be made from such spontaneously expelled material, or
from the particles obtained by a uterine eurettement. Suspicion of a

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

143

pregnancy may be aroused by the presence of proliferating glandular
tissue as described in the chapter on Pathology, and by the presence of
decidua cells. Many have contended, and it seems to me with reason,
that the positive diagnosis of an abortion can be made when large islands
of typical decidua cells are found in the curetted particles. To those
who have examined many such specimens, the differentiation between
such deciduous areas and those found in menstruation or in interstitial
endometritis is comparatively easy. If the number of decidua-like cells
is few, and they are scattered, no positive conclusions can be drawn from
their presence. A certain microscopic diagnosis can be made by the find¬
ing of a single chorionic villus and typical proliferating syncytium.
Such a picture can be produced by no other pathological condition and
is of special value in the testimony of cases of criminal abortion.

Diagnosis of the Stage of Abortion

It is not enough, in a given case, merely to determine the fact that we
are dealing with an abortion. We must further seek to determine in
what stage the abortion may be, for the treatment differs radically, de¬
pending upon this factor. In general we speak of threatened abortion
when definite symptoms have set in, but it is still possible that the
expulsion of the ovum may be prevented. Inevitable abortion is the term
applied when it is no longer possible to check the expulsion. Abortion
is spoken of as incomplete when portions of the ovum are still left in the
uterus. Complete abortion refers to the condition immediately after the
expulsion of the ovum has been fully accomplished. Recent abortion is
the condition several days after complete expulsion of the ovum. Each
of these five stages in the expulsive process has distinctive signs and
symptoms, and must be carefully differentiated.

Threatened Abortion. — This is indicated by a vague feeling of ma¬
laise, headache, backache, and increased frequency of urination. After
these symptoms have persisted a day or so there is usually a show of
blood in the vaginal discharge and a few abdominal cramps.

Inevitable Abortion. — Abortion can usually be considered inevitable.

(1) When the amount of blood lost is considerable or the bloody dis¬
charge prolonged for several weeks.

(2) When the pains become severe, occur at regular intervals, and
are of a cramp -like character.

(3) When the cervix is dilated sufficiently to admit one finger.

(4) When there has been a watery discharge indicative of a rupture
of the membranes.

(5) When the fact of fetal death has been determined.

144

ABORTION

The diagnosis becomes more certain if several of these factors have
been established. Boldt declares that if there is present a persistent
bloody grumons discharge, even without any marked pains or cervical
dilatation, an abortion is inevitable. The extent of cervical dilatation is
of diagnostic value chiefly in primiparae. In women who have had chil¬
dren, there may be considerable cervical dilatation without any inter-
ruption of gestation.

One of the questions that we are often called upon to answer, is :
TIow long can I let this woman bleed before changing my diagnosis of
threatened abortion to one of inevitable abortion? The question is not
always easy to answer, for we must be guided by the total quantity of
blood lost, the severity of uterine contractions, the methods of treatment
previously employed, and by the patient’s reaction to them. Whether
the bleeding has lasted several weeks or not, abortion is not usually to
be considered inevitable until the usual measures to check bleeding and
expulsive pains have been tried in vain.

In general, we may say that where treatment produces no decided
effect within one week an abortion is likely to occur. Bleeding prolonged
over three weeks is rarely attended by continuation of pregnancy. A
word of warning, however, should be given against using the watch and
the calendar in the determination of this question. Our judgment must
be based upon a consideration of all the various factors.

A sign of inevitable abortion emphasized by Tarnier is the effacement
of the acute angle, formed anteriorly between the neck and body of the
pregnant uterus. This effacement indicates a contraction of the longi¬
tudinal fibers of the uterus, and hence a descent of the ovum itself, owins
to dislocation from its site of attachment.

Rock says that if the flow of blood in 24 hours equals the height
of the usual menstrual flow, the chance of saving the pregnancy is small,
especially if this bleeding is associated with the onset of regular painful
contractions. Fresh blood indicating persistent bleeding is of greater
importance than dark red or brown discharge. Five napkins soaked with
d o e day or five days of three napkins each points to in¬
evitable abortion. Rock also considers intermittent contractions as more
favorable than continuous ones. Even so, it is important to establish
a definite formula for the general practitioner. Naturally if an error
is to be made it should be rather on the side of conservatism, trying to
preserve the pregnancy, whenever possible, especially in those cases where
a child is greatly desired.

Incomplete Abortion. — It is often extremely difficult to determine
with certainty whether expulsion of the uterine contents has been com¬
pleted. Consideration of the clinical course and the bimanual examina¬
tion will usually solve the question. Of the clinical signs the continuance

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

145

of profuse bleeding points to retention of placental tissue. Normally we
find after abortion a moderate bloody discharge which within a day or
two becomes very slight. If tissue lias been retained the llow remains
brighter red and clotted, with an increasing odor to the discharge so
that in five or six days it becomes unbearably offensive. There are
usually noticeable waves of uterine contraction and a somewhat per^
sistent backache.

Characteristic of the retention of portions of the ovisac is the reaction
to ergot. Especially in abortion of the third month or more, we find that
there is a noticeable increase in the strength and regularity of the painful
uterine contractions within one hour after the ergot is administered if
there is material inside the cavity.

In the physical examination of cases of incomplete abortion we espe¬
cially observe the openness of the cervix and the relatively large size of
the uterus itself. Naturally the duration of the pregnancy will have to
be considered in determining whether or not the uterus is still abnormally
enlarged. Increased softness also points to retention of placental tissue.
If the cervix is large enough to admit a finger tip, it may be possible
actually to feel such particles of retained placenta. In abortions of the
first month or two, the cervix may be entirely closed and the uterus uni¬
formly firm in spite of the fact that material has still been retained.
When symptoms point to the possibility of such retained material it
will usually be wiser, provided the patient is in a hospital, to proceed
with a curettement even though such a procedure will at times bring
away very little additional material. As will later be discussed in the
chapters on Treatment, many physicians prefer to do a routine curet¬
tage in all afebrile abortions even without definite evidence of pla¬
cental retention.

Diagnosis as to whether or not an abortion is complete is rendered
more certain if all material that has been expelled is saved and carefully
inspected. Under the head of Mechanism of Abortion will be found a
description of the physical appearance of the ovisac under various condi¬
tions. All blood clots must be carefully teased apart to exclude the possi¬
bility that they conceal parts of the ovisac. The transparent jelly-like
appearance of the ovisac in the earlier months covered by the coral-like
projections of the chorionic villi is quite characteristic. The smooth,
somewhat striated, grayish red appearance of the decidua is also note¬
worthy. The fetus, especially in cases of retained abortion, may be so
macerated as to be barely recognizable as a brownish amorphous mass.
The retinal pigment in these cases resists disintegration and the two
black dots in the amorphous mass may be the only positive evidence that
we are dealing with a fetus. In cases of blighted ovum the intact

146

ABORTION

amniotic sac may be opened and reveal no visible evidence of the embryo.
Since much valuable information both as to retention of portions of
the ovisac and as to possible causes for the abortion can be obtained
by careful gross examination of the tissues expelled, it is important to
ask patients to preserve such bits of tissue in a jelly glass or jar and
cover them with dilute alcohol (half strength commercial) for this pur¬
pose.

Recent Abortion.— Recent abortion, that is to say, abortion that has
occurred anywhere from two to fourteen days previously, occasionally
demands diagnosis for medico-legal and therapeutic reasons. Especially
where the suspicion of criminal interference is at hand, a careful diag¬
nosis is of the greatest importance. On digital examination we find,
in abortions that have recently occurred, a rather free, usually blood¬
stained or brownish discharge, a patulous cervix and a somewhat en¬
larged uterus that is still a trifle softer than normal. From the micro¬
scopic examination of curetted particles, or from the uterus at autopsy
where death has occurred, we can determine the presence of typical
decidua, or of chorionic villi. The uterine cavity at autopsy usually
presents a somewhat shaggy appearance at the site of the placenta.

Diagnosis of Fetal Death

Since on the one hand conditions may arise producing death of the
fetus without arousing any uterine contractions, bleeding, or other symp¬
toms of threatened abortion, and since, on the other hand, fetal death
obviously indicates an impossibility of carrying the child to term, it be¬
comes a matter of diagnostic importance to determine whether fetal
death has occurred. Naturally if by careful observation no progressive
enlargement of the uterus is noted, it is fair to assume that fetal death
has occurred. Since these facts, however, are usually very difficult of
determination except after a month or two, efforts have been made to
supplement physical examination by laboratory tests. An interesting
observation has been made and confirmed that the so-called pregnancy
test already referred to becomes negative approximately two weeks after
fetal death has occurred. Characteristic of this group of cases, in which
the dead ovum is retained for a long period, is the fact that this process
occurs most often in women who have been previously sterile, that it is
characterized by a prolonged, bloody vaginal discharge of a crumbly,
brownish character, and that uterine contractions are usually very slight
or entirely absent. With such a history we should at the end of two
or three weeks do a pregnancy hormone test. According to Brindeau,
if the pregnancy test is carried out on a quantitative basis, it will in the
case of retained dead ova show a strength of 80 to 500 units as compared

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

147

with the 2,000 to 3,000 units normal in pregnancy and an abnormally
high positive of 300,000 units in cases of hydatidiform mole.

B . Non.- stimulated rat's uleras
C- Cross -section of B (enlarged)

F Megodive vaginal smear.

Fig-. 46. — Female

X). Castrated rat's uterics, stimulated .
E. Cross-section of I> Cehlarged)

In discussing the hormone diagnosis of the viability of the fetus, Spiel-
man, Goldberger and Frank studied in 33 cases of certain or suspected
fetal death the presence of female sex hormone and prepituitary hormone.
They found that the Aschheim -Zondek test, if negative, indicated that

148

ABORTION

the fetus was dead, but, if this test was positive, the fetus might be
either dead or alive, and the test was correct in only 50 per cent of their
cases. On the other hand, the female sex hormone test, as elaborated
by Robert Frank, was 100 per cent correct. Twenty-three cases were
negative with dead fetus; eight cases positive with living fetus; and two
placental retentions with positive fetal sex hormone test (Fig. 46). Ac¬
cording to these investigators the relative inaccuracy of the Aschheim-
Zondek test in these cases is due to the presence of quantities of prep it ub
tary hormone so large as not to be readily eliminated after fetal death,
especially if the placental tissue was still viable. On the other hand, the
fetal sex hormone test became negative relatively early after fetal death
and hence was definitely to be preferred in the laboratory diagnosis of
this condition.

Diagnosis of the Cause of Abortion

The question of the cause of a spontaneous abortion will at times
present serious difficulties. Careful inspection of the ovisac may point
to a defective germ-plasm as the etiological factor. In more advanced
pregnancies the possibility of placenta previa must be considered. The
presence of infarcts may point to toxic or infectious factors. The char¬
acteristic placental changes found in syphilis with a positive Wassermann
may establish the diagnosis. Medical examination of the patient may
reveal a diabetes, kidney or heart lesion, or other disturbing factors.
Locally, we may find on bimanual examination a deeply lacerated cervix,
a retroversion or prolapse, or the presence of myomatous tumors that
point to the cause of the abortion.

Most important of all is the differentiation between spontaneous and
induced or criminal abortion. All such criminal manipulations have
the inherent possibility, even probability, that infectious organisms may
have been carried into the uterine cavity, so that subsequent active treat¬
ment such as a curettement may lead to the spread of such infectious
material into the maternal circulation, thus producing a septicemia.
The fact that the patient herself is apt to deny, for obvious reasons, any
such previous manipulations makes it important to consider other ob¬
jective findings in arriving at a diagnosis. In abortion of the first three
months rupture of the membranes, associated as it is with a tendency to
separate expulsion of embryo and placental tissues, is presumptive evi¬
dence of previous instrumentation. The presence of fever early in the
course of abortion also points to criminal interference. Bleeding is
likely to be more profuse and sudden in its onset in such cases.

The proportion of induced abortions after the third month of gesta¬
tion is relatively small. Magid, in an analysis of 578 cases with a view

diagnosis and differential diagnosis

149

to making a differential diagnosis between spontaneous and induced
abortion, found that criminal interference was proved in about 30 per
cent of the cases that had fever, and in only 12 per cent of those without
fever. A careful questioning of the patients will often help in the
diagnosis. The sudden acute onset, in a patient previously well, the his¬
tory of some minor accident without evidence of any trauma, a chill oc¬
curring soon after the onset of the abortion, and delay in seeking medical
assistance, arouse suspicion of intrauterine interference, even where this
is denied.

Occasionally, we may find on specular examination of such a patient
small puncture wounds of the cervix, where it was grasped with a
tenaculum, or other evidences of direct trauma to the cervix or upper
vagina through instrumentation. If these wounds show evidence of be¬
ginning infection, the diagnosis of induced abortion is even more certain.

Differential Diagnosis

In the differential diagnosis between abortion and other pelvic condi¬
tions the following deserve special consideration.

(1) Irregular menstruation of functional origin

( 2 ) Membranous dysmenorrhea

(3) Myoma of the uterus

(4) Carcinoma of the uterus

(5) Ectopic pregnancy

(1) Irregular Menstruation of Functional Origin. — It is not at all

uncommon to meet with women who have spells of amenorrhea of three to
four months7 duration, which are followed by a free bloody discharge,
with cramps and the passage of clots. To say in any one instance that
the case is not an abortion is not easy. The previous menstrual history,
as well as the fact that on examination the uterus is of normal size and
consistency, will usually clear the diagnosis. It is the amenorrhea that
leads to the assumption of a pregnancy, and later the patient is apt to
interpret the sudden profuse return of menstruation as the onset of an
abortion. The liquid character and dark color of menstrual blood is of
considerable diagnostic value. Frequently we are called upon several
weeks and even months after such a bloody discharge from the uterus
to decide whether or not it was an abortion. Where we have only the
patient’s statement to guide us, it is impossible to give a positive answer.

(2) Membranous Dysmenorrhea. — (Fig. 47.) While the usual clini¬
cal manifestations of endometrial hyperplasia are readily differentiated
from abortion, we meet at times with patients who expel the entire endo¬
metrium as a sac that grossly resembles an early intact abortion or frag¬
ments that have a shaggy appearance like decidua. These are the women

150

abortion

who report innumerable miscarriages. This condition known as
dysmenorrhea* membranacea is characterized by severe cramp-like pains,
not markedly different from those of abortion, and ceasing with expulsion
of the sac. There is usually more than the regular amount of menstrual
bleeding with a tendency to the expulsion of clots. The absence of previ¬
ous amenorrhea with symptoms of pregnancy, the tendency to regular
or often repeated expulsion of such uterine casts at the monthly period
and the careful inspection of such casts showing complete absence of any
chorionic sac, will ordinarily point to this diagnosis. Microscopic exam¬
ination of the tissue expelled showing absence of chorionic villi and
decidua will confirm it.

(3) Fibroid Tumors. — Fibroid tumors, especially of the submucous
type, may cause the uterus to appear softer and more spherical, but
here there is apt to be a history of profuse and too frequent menstruation.
The value of a good clinical history becomes evident, since the physical

Fig-. 47. — Differential diagnosis between membranous dysmenorrhea and abortion.
A. Cast of uterine mucosa in membranous dysmenorrhea. B. Early abortion sac of
similar size. <7. Abortion sac opened to show embryo.

findings may permit of no differentiation. As a rule, however, careful
palpation will show in cases of fibroid tumors some irregularity of out¬
line and consistency. In more advanced cases of abortion (third to fifth
month), the similarity between them and submucous fibroids in process
of expulsion into the vagina must be kept in mind (Fig. 48). Both may
give rise to profuse hemorrhage and an odorous discharge of necrotic
material. The history of amenorrhea, increased softness of the pregnant
uterus, greater friability of placental tissue over fibroid tissue, render
the differentiation comparatively simple. The pregnancy hormone test
will give positive evidence of the existence of a pregnancy, but may be
negative in cases of retained abortion. The diagnosis may be complicated
by a combination of abortion in a myomatous uterus.

(4) Cancer of the Uterus. — Cancer of the uterus must likewise be
distinguished from abortions. If the cancer be located in the cervix
this will not be difficult, but if it be located in the body of the uterus the

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

151

Fig. 48. — Cross-section of uterus containing necrotic myoma. A perforation was
made by a midwife under tjie assumption that the patient was pregnant, thus com¬
plicating the subsequent hysterectomy. Case of Drs. H. S. Crossen and C. O. C. Max.
(Crossen: Diseases of Women.)

152

ABORTION

differentiation will liave to be based, to a considerable extent, on the
patient’s history (Fig. 49). Cancer of this type rarely appears at an
age when child-bearing is likely to occur, but when it does, the continuous
bloody discharge with passage of clots and necrotic shreds may closely
simulate an abortion. Here the microscope is necessary to clear up the
nature of the trouble. We must remember, however, that a form of
malignant tumor of the uterus, called chorio-epithelioma, from the fact
that it develops from the chorionic epithelium, occasionally arises after

an abortion.

(5) Tubal Pregnancy. — Most difficult is the differentiation between
tubal pregnancy, or, rather, tubal abortion, and intrauterine aboition,
especially when the latter is associated with inflammatory trouble of the
adnexa. It is a very common event to have a uterus curetted on the sup¬
position that there is a post-abortive retention of the placenta, only to
discover a little later that the correct diagnosis was extrauterine preg¬
nancy. To keep from making such mistakes we must bear the following

points in mind:

In the history of the case we are apt to have in uterine abortion a
longer period of complete amenorrhea before bleeding starts. Tubal
abortion is more apt to occur between the fourth and the sixth week,
whereas uterine abortion occurs with greatest frequency between the
eighth and twelfth week. In tubal abortion the onset of pains and
bleeding is often attended by dizziness or even fainting, owing to the
shock of intra-abdominal hemorrhage. Furthermore, the cramps or sud¬
den stabs of violent pain are felt on the affected side, whereas in uterine
abortion the cramps are directly in the hypogastrium, coming and going
like menstrual pains or labor. Vomiting, due to peritoneal irritation, is
more often found in tubal gestation.

The character of the bleeding is of some differential value. In tubal
abortion, for instance, only small fragments of decidual tissue are ex¬
pelled from the uterus; the bleeding is never active and often there is
only a prolonged brownish discharge. In uterine abortions, on the other
hand, there are apt to be many clots, a copious bleeding, and pieces of
decidua or placental tissue expelled. Again, in tubal abortion bimanual
examination reveals a slightly enlarged uterus with a one-sided oval or
sausage-shaped mass, the size of a fist or even larger, extremely sensitiv e
to pressure, rather boggy to the touch, semi-fluctuating, adherent; where¬
as in uterine abortion we have a more or less spherical, enlarged uterus,
not sensitive, with perhaps a one-sided or double-sided mass of variable
size depending on the amount of associated inflammatory trouble in the
adnexa (Fig. 50). If this inflammatory mass is sensitive, there are apt
to be several degrees of fever, 101° to 103°, whereas it is the rule in tubal
abortion for the thermometer to register only 99.5° to 100°. The pulse,

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

153

Fig-. 49. — Differential diagnosis between early pregnancy, myoma of the uterus, and

adenocarcinoma of the uterine body.

154

ABORTION

on the other hand, is more often rapid in the latter condition, ranging
between 100-130 in accordance with the extent of the internal hemor¬
rhage. The differential diagnosis will occasionally be impossible until the
patient has been under observation for some time.

Another trying element in the management of these cases is the un¬
willingness of the patient to be confined to her bed or go to a hospital for
observation. Wishing something done at once, she often hurries the
physician into measures whose consequences are fatal to the patient.
Many cases of tubal pregnancy are on record where a hurry-up diagnosis

DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS

155

of retained placenta was made and the uterus emptied digitally or with
a curette, only to have the patient collapse from internal hemorrhage
and shock immediately afterward, and die before she could be taken to
the hospital to be operated on.

The material expelled should be saved, and sectioned microscopically.
The presence of chorionic villi or epithelium is proof of an intrauterine
pregnancy, whereas, if decidua alone is found on examining many sec¬
tions, one may be very suspicious of tubal pregnancy especially if a
tender adnexal mass is present. In this connection we must remember
that there are now on record in the neighborhood of one hundred cases
of combined extrauterine and intrauterine pregnancy. Hence the possi¬
bility of such an event, in spite of its rarity, must be kept in mind in
making a diagnosis.

To summarize once more the differentiation between tubal abortion and
uterine abortion we have :

TUBAL ABORTION

( 1 ) Occurs most often between 4th and
6th week.

(2) Pains severe, one-sided, attended
with faintness and at times vomit¬
ing.

(5) Bleeding moderate, chocolate col¬
ored, crumbling. Decidua at times
expelled intact as a cast.

( 4 ) Bimanually, uterus only slightly en¬
larged.

(5) Bimanually, a mass to one side,
semi-fluctuating, sensitive, often sau¬
sage-shaped, boggy to the touch.

( 6 ) Temperature 99.5° to 100°.

(7) Pulse 110 to 130.

(<?) Pieces from uterus show only de¬
cidua microscopically.

( 9 ) Marked leucocytosis (20,000-25,000).

UTERINE ABORTION

(1) Most frequent between 8th and 12th
week.

(2) Pains moderate, central, often
rhythmic.

(5) Bleeding copious, reddish, clotted.
Placental pieces or decidua expelled,
necrotic odor at times.

(4) Bimanually, uterus enlarged in ac¬
cordance with stage of pregnancy.

(5) Bimanually, usually normal tubes
and ovaries; if associated with tubal
infection, a mass sensitive to touch
and semi-fluctuating can be felt, one
side or both.

( 6 ) Temperature (in cases of uterine or
tubal infection) 102° to 103°; other¬
wise normal.

(7) Pulse 80 to 100.

(<?) Pieces from uterus show chorionic
villi or syncytium with decidua mi¬
croscopically.

( 9 ) Leucocyte count slightly elevated.
(10,000-15,000).

CHAPTER XI

TREATMENT OP ABORTION

CERTAIN PHASES of the treatment of abortion are considered in
other chapters. Threatened abortion is discussed under the head
of prevention; and perforation, extra-uterine septic infection, other
complications, and therapeutic abortion are treated separately under
these heads.

Historical

A brief review of the treatment of abortion in the past centuiy is
of interest preparatory to the discussion of the present conflict be-
tween those advocating active treatment and those advising conserva¬
tive measures. Before the nineteenth century the measures employed
consisted mostly of medicines or of external applications.

In 1806, John Burns of Glasgow published an interesting series of
“Observations on Abortion’" in which he advised “plugging of the
vagina” for the control of hemorrhage, (p. 102 f t) “This is best
done,” he says, “by taking a pretty large piece of soft cloth and
dipping it in oil and then wringing it gently. It is to be introduced
with the finger, portion after portion, until the lower part of the
vagina be well filled. The remainder is then to be pressed firmly on
the orifice and held here for some time. This acts by giving the
effused blood time to coagulate. It gives no pain, it produces no irrita¬
tion, and those who condemn it, surely must either not have tried it,
or have misapplied it. . . . In obstinate cases we may, before intro¬
ducing the plug, insert a little powdered ice, when it can be procured,
tied up in a rag.”

Digital removal of the fetus and placenta, Burns does not recom¬
mend, but he adds: “I do not wish to be understood as altogethei
forbidding manual assistance ; but I am much inclined to consider it
as a useful precept, not to be hasty in extracting the ovum.” If the
placenta is retained, he advises that the finger be introduced and
the remains of the ovum slowly detached by very gentle motion ; and
we must be very careful not to endeavor to pull away the seeundines
until they are fully loosened, for we thus leave part behind, which
sometimes gives a great deal of trouble.” Inflammation and “other
hysterical symptoms” sometimes follow. “When this disease proves

156

TREATMENT OF ABORTION

157

fatal, there are often, though not always, conjoined symptoms of
gangrene, weak fluttering pulse, cold sweats and hiccough.”

Dewees in 1843 recommended the use of acetate of lead as an as¬
tringent to control bleeding. Hodge, in his " Principles and Practice
of Obstetrics” (1864), considered the wire crotchet (Fig. 51) for
removing the ovum, devised by Dewees, too dangerous and in place
of it used a small blunt lever, or ovum forceps (Fig. 52). These blunt
instruments are slowly revolved within the uterus to loosen the pla¬
centa before extracting it. In cases of retained placentae Hodge says
(p. 469), "the practitioner may patiently wait for the occurrence of
uterine contractions. Even if a part of the ovum can be felt, no
attempts should be made to extract it, as hemorrhage may be excited.
If a portion be projecting, and the hemorrhage great, its descent may

Fig. 51. — Dewees’ wire crotchet.

Fig. 52. — Hodge’s ovum forceps.

be facilitated by one or two fingers in the vagina, provided the secale
cornutum, cold, etc., have proved inefficient. . . . All such artificial
assistance is however very seldom demanded.”

Somewhat bolder is the treatment recommended by T. Gaillard
Thomas in his little monograph on "Abortion” (1896). He recom¬
mends the use of an ordinary large curette for the removal of retained
placental tissue. If at this time pressure is made over the fundus by
one of the attendants, "you will be amazed to find how quickly the
uterine contents will roll out.” Thomas, however, still preferred to
treat the majority of cases by a careful tampon applied to the cervix,
if it is sufficiently dilated, as well as to the entire vagina. The im¬
provement in antiseptic methods is noted in his directions for sterili¬
zation by boiling and by using carbolic acid, bichloride or iodoform.
If the ovum is still intact, he considers that "the tampon is the remedy
in abortion. . . . With the tampon in position, you may go about your

158

ABORTION

work feeling perfectly at ease. Your main duty consists in not inter¬
fering*. Nature is perfectly competent to carry on her work to com¬
pletion without your aid.”

In Germany we find a similar tendency to conservatism at this time.
Hegar in 1862 advised against active treatment especially in the
presence of fever ; but toward the end of the century that ardent
gynecological operator, Diihrssen (1887) came out with the state¬
ment that the immediate evacuation of the uterus was demanded in
all cases of abortion. This principle was soon generally accepted,
although there was some difference of opinion as to whether the finger
or instruments should be used for this purpose. The curette, first
recommended for retained placenta by Spiegelberg in 1876, became
the popular instrument. In the first decade of the present century,
almost all gynecologists employed active treatment in cases of in¬
complete abortion.

As a sequel to this wide-spread operative furor, cases of perfora¬
tion, peritonitis and septicemia began to be recorded. A few warn¬
ing voices were raised, but it remained for Winter, in 1911, to show
conclusively that only by conservative measures could the evacuation
of the uterus be accomplished without risk of spreading infection or
traumatizing the pelvic organs. The increase in criminally induced
abortions, with their high percentage of infections, made it more
necessary than ever before to adopt a waiting policy. How far we
should go in this conservatism will be latter discussed in detail, but
certainly we owe a debt of gratitude to Winter for his careful scientific
study of this important problem.

Differentiation of Clean and Infected Cases

The outstanding point in the dialectics following upon the pub¬
lication of Winter’s paper, which has engaged the attention of
gynecologists throughout the world since that time, is that we must
differentiate in our treatment between the clean cases and the in¬
fected, or potentially infected, cases. To speak of them as afebrile or
febrile abortions is not a good method of classification since we may
at times have febrile cases that are not infected, and absence of fever
by no means excludes the possibility of such infection. Yet in the
effort to define what we wish to include under the head of septic
abortion, the rise of temperature is perhaps the most reliable index,
and the safe rule is:

If the temperature be over 38° C. (100° F.) for more than twenty-
four hours the case should be considered septic.

TREATMENT OF ABORTION

159

Both the history and the course of the abortion must however be
taken into consideration. If the abortion has been induced by patient,
midwife or abortionist, the chances for contamination with septic
organisms is so great that the case must be handled as though in¬
fected, even if there is no fever. The history of such interference
will be difficult to obtain but early rupture of the membranes, early
severe bleeding and traumata about the cervix or upper vagina, will
make such a diagnosis more than probable. On the other hand, if the
ovisac or blood-clots have been retained in the cervix and vagina, and
putrefaction has taken place, the resulting rise of temperature and
discharge does not necessarily indicate uterine infection, especially
if it falls promptly upon the expulsion of this material.

Laboratory tests may help us in two ways to differentiate between
the infected and the non-infected cases: (1) A study of the blood
picture; and (2) bacteriological examination of the vaginal and
uterine secretions and the blood.

Schilling Hemogram. — The study of the blood picture became of
far greater value after the epoch-making work of Schilling on the
juvenile and degenerative forms of the neutrophilic leucocytes (“Das
Blutbild, ” 1926). Whereas formerly we relied largely on the leucocyte
count alone, with a differential count merely pointing to increase in
polynuclear leucocytes in cases of infection, we now have an index
that is of great value in the diagnosis of infection, and of even greater
prognostic importance.

In the normal blood count there are per 100 leucocytes, 1 basophile,
3 eosinophiles, no myelocytes or juvenile forms, 4 stab-cells, 63 seg¬
mented neutrophiles, 23 lymphocytes and 4 mononuclear cells. In
cases of infection basophiles and eosinophiles are absent; lymphocytes
and mononuclears are reduced to half their number ; and the neutro¬
philes are increased from a total of 67 to 80 or 90. Most significant
is the ratio in the neutrophiles. Myelocytes and juvenile forms are
present, their number increasing with the seriousness of the infection
as measured by the virulence of the invaders and lack of resistance
of the invaded host. Stab-cells are increased to eight or ten times
that of the normal count and segmented forms are proportionately
reduced.

While valuable information can be obtained from a single Schilling
blood picture, even greater importance is to be attached to the com¬
parison of repeated blood examinations. From them we can visualize
the progress of the infection, whether it is being localized, whether
the resistance of the patient is being maintained, or whether an over¬
whelming infection will lead to death in a short time. While it is

160

ABORTION

unwise to base prognosis solely upon any laboratory test, experience
has shown that repeated Schilling tests rarely fail to give accurate
information concerning the progress of the infection. Particularly in
cases of severe septic abortions will such a blood count be a valuable
aid in the management of the case and be a guide as to when or
whether to interfere in an operative way.

A single illustration taken from Schilling will serve to demonstrate
the value of these tests. In Table I it will be noted that the infection
grew worse from April 11th to 17th, but that on the 18th eosinophiles
again appeared and myelocytes disappeared indicating increased re¬
sistance. In eight days more the eosinophiles were still more num¬
erous, juvenile forms were no longer seen, stab-cells were reduced to
half their former number and lymphocytes returned to normal. By
May 5th the blood picture was almost normal, except for the still
elevated eosinopliile count. The blood counts correspond closely to
the clinical progress of the case, except that the changes in the blood-
picture usually precede by several days the alteration in the patient’s
general condition. In a study of the blood count in appendicitis J.
Y. Luck has shown that in fatal ruptured cases with peritonitis the
total white count would often be between 4,000 and 8,000 with as
many as 4 to 10 myelocytes and between 28 to 52 juveniles. Similar
blood counts are present in the severe fatal cases of peritonitis and
septicemia following septic abortion.

Table I

Blood Picture in Septic Abortion with Lung Metastasis
( From Schilling : 1 i Das Blutbild ’ ’ )

(day)

(1)

TOTAL

WHITE

COUNT

(2)

BASO-

PILILES

(3)

EOSINE-

PHILES

(4)

MYELO¬

CYTES

(5)

JUVE¬

NILES

(6)

STAB-

CELLS

(7)

SEG¬

MENT

CELLS

(8)

LYM¬

PHO¬

CYTES

(9)

MONO¬

NU¬

CLEARS

Normal

7,500

(1st)
April 11

Much

Increased

(7th)

April 17

9,400

(8th)

April 18

Increased

(16th)

April 26

Increased

(26 th)

May 5

8,500

Bacteriologic Tests. — The second laboratory test of value in the
diagnosis and management of septic abortion is bacteriologic exami¬
nation of the vaginal and uterine secretions and the blood. There is,

TREATMENT OF ABORTION

161

however, considerable debate as to how much reliance can be placed
upon it. During pregnancy the vagina frequently contains strepto¬
cocci and other organisms that may, under favorable conditions such
as bleeding and traumatized wounds, become pathogenic. S. Soule and
T. K. Brown studying 207 cultures from the vaginas of normal preg¬
nant women found anaerobic streptococci in 40 per cent of the cases,
but in no instance were hemolytic streptococci present. Two years
before Brown had analyzed the bacteriologic findings in 112 cases of
puerperal sepsis, over a third of which followed abortion, and found
that the anaerobic streptococcus was the offending organism in the
large majority of cases.

When unsterile attempts at inducing abortion lead to further con¬
tamination beyond the organisms already present, bacteriologic ex¬
aminations of vaginal and uterine secretions may have definite value.

A. B.

Fig-. 53-A. — Colonies of Streptococcus hemolyticus on blood ag-ar. Note that all
the blood c-ells have been dissolved. (From Gradwohl : Clinical Laboratory Methods
and Diagnosis, The C. V. Mosby Co.)

Fig-. 53. -U. — Colonies of Streptococcus viridans on blood agar. Note only partial
hemolysis of blood cells. (From Gradwohl: Clinical Laboratory Methods and
Diagnosis. )

Such examinations should be made by one who has had special ex¬
perience in the study of puerperal infections since the average bac¬
teriologist is often not qualified to make the special differentiation of
organisms required for this work. Furthermore, as Heynemann justly
emphasizes, the bacteriologic findings must always be considered side
by side with the clinical picture before drawing any conclusions.

Virulence Test. — Special value has been placed by Waitz, Kubinyi
and others upon the so-called Ruge-Philipp virulence test. This con¬
sists of growing bacteria in the defibrinated blood of the patient.
More important than the method of growth is the careful diagnosis of the
particular organisms present (Fig. 53). Here we come to an important
practical difficulty, for the clinician cannot wait too long in deciding
upon the diagnosis and plan of treatment and the conscientious bac-

162

ABORTION

teriologist must confess his inability often times to establish the
identity of organisms except by further cultures that may require
several days additional time.

In Germany it was claimed by Winter and Waltliard that in the
presence of hemolytic streptococci all intrauterine manipulations were
contra-indicated. The contradictory findings however when bac-
teriologic tests were repeated, and the failure to improve clinical results
by adopting this rule led to a swing of the pendulum in the opposite
direction. I think Heynemann is correct in believing that this counter¬
movement has gone too far. If we recognize the necessary limitations
of these laboratory tests, we can utilize them to advantage in connec¬
tion with the clinical findings. The presence of the hemolytic strepto¬
coccus, hemolytic staphylococcus, or anaerobic streptococcus putridus
in the vaginal or uterine culture, should make us hesitate with instru¬
mentation or digital exploration, even where no signs of extension of
infection beyond the uterus are present. Simple drainage of the
uterine cavity by means of an alcohol gauze wick would not seem to
be so dangerous, since in 40 cases treated without fatality by G.
Schwarz in this manner, 12 showed hemolytic streptococci and several
others hemolytic staphlylococci. Krieger, using a similar technique
in 128 cases found hemolytic organisms, 24 times in the vaginal secre¬
tions and 4 times in the blood with but one death.

Table II

Infectious Agent Found in Blood or in Peritoneal Pus Before Death
(From Schottmiiller : Mimclien. Med. Wclmschr. Vol. 57.)

organisms

IN ORDER OF

FREQUENCY

(1)

TOTAL

(2)

CASES OF

SEPSIS

(3)

CASES OF

PERITONITIS

Total Cases

231

142

Streptococcus hemolyticus

Streptococcus putrificus (anaerob.) -

Staphylococcus aureus or albus

Bacillus emphysematosus Fraenkel -

Pneumococcus

Bacterium cob

—

Anaerobic staphylococcus

—

Mixed infections

All more active procedures, however, that would tend to break
down the natural barriers that have been erected by the patient to
combat the infection should be delayed, if practical, until the bac-
teriologic findings have been given due consideration. Winter’s re¬
ports of 30 per cent mortality in 130 cases where hemolytic strepto¬
cocci were present and 86 per cent mortality in 14 cases where they
were in pure culture, is contrasted with 2.4 per cent mortality in 211

TREATMENT OF ABORTION

163

cases where other organisms were found. The accompanying table
from Schottmiillers5' study of 231 fatal cases of septic abortion gives
a good picture of the relative importance of the various organisms
found.

Not merely the identification of the offending organism, but a de¬
termination of its virulence should be our aim. All attempts to
accomplish this, even the new Riige-Pliilipp virulence test, have failed
to be sufficiently accurate to be of practical value. According to Hey-
nemann, infections due to the gas-bacillus, Bacillus emphysematosus,
Fraenkel (or, more properly, Bacillus aero genes capsulatus, Welch ,
since Welch described it four years before Fraenkel), demand special
consideration. This organism is usually limited to the uterus for some
time. Prompt evacuation of the uterine cavity is indicated or, in cases
of beginning peritonitis, a hysterectomy rather than the conservative
measures recommended in cases of streptococcus infections.

All these detailed bacteriological examinations can with difficulty
be applied in general practice where adequate facilities for such
studies are not at hand. For maternity hospitals and wards they are
of unquestioned diagnostic value and must be given due considera¬
tion, especially if the organisms are found in pure culture.

From the temperature rise, the history and clinical findings, and
the blood and bacteriological examinations, we should therefore be in
a position to separate with reasonable accuracy the clean and septic
cases.

Synopsis of Clinical Experience

A vast amount of clinical experience has been recorded in medical
literature, especially comparing the active, expectant, and conserva¬
tive treatment of abortion. Reports before 1920 have been sum¬
marized in text books and monographs, and for our purposes a review
of the more recent literature will suffice, before proceeding to a con¬
sideration of treatment. In the following summary reports are
grouped geographically, and in all these cases the mortality rate is
given in terms of per cent.

Sweden. — In Mahno, Lindqvist (1931) analyzed 2,047 abortions with
25 deaths, a rate of 1.2 per cent. In all 1,593 were clean and 454
(22 per cent) septic. The mortality rate was only 0.3 in the clean;
but in the septic, with temperature up to 38.5° (102° F.) it varied
from 2.3 in cases of one to three months gestation, to 5.9 in those of
four to six months, and where the temperature exceeded 38.5° (102°
F.) the rate was 5 for the first two months and 13 for those from three
to six months gestation.

164

ABORTION

Bovin studied the results of expectant treatment in 1,141 febrile
cases (over 38°, 100° F.), excluding those with extra-uterine and com¬
plete abortions. In 623 treated expectantly, the mortality rate was
1.3 j while in 518 for which prompt evacuation was preferred, it was
2.9 per cent. The septic cases studied formed about 30 per cent of
the 3,809 total in this group.

In Upsala, Glow (1923-29) reports on 740 abortions of which 300
were infected and 440 non-infected. Immediate intervention was done
in 348 ; intervention after expectant treatment in 282 ; and expectant
treatment alone in 107, with results that justified active treatment.

Norway. — In Oslo , Harbitz (1931) reports on a series of 3,791 abor¬
tions with 82 deaths, a mortality rate of 2.2 per cent. But of the 1,871
afebrile cases there were only 7 deaths, or a rate of 0.37, compared
with 75 deaths in the 1920 febrile cases, a rate of 3.8. In other words
the febrile cases were ten times more fatal than the afebrile. And of
the 129 febrile patients with complications, 44 died, or 34 per cent.

Details of Harbitz * report are shown in Table III. It is noted that
no deaths followed the 201 uncomplicated febrile cases treated con¬
servatively, and that the next best showing was among those treated
actively after fever had dropped. Of the 129 complicated febrile
cases, 85 recovered including 37 patients with pelvic abscesses, 19

Table III

Abortion Treatment and Results (Oslo)

(After Harbitz: Acta obst. et gynec. Scandinav. 11: 50, 1931.)

ABORTION :

NATURE AND TREATMENT

(1)

(2)

(3)

(4)

CASES

DEATHS

NUMBER

PER CENT

NUMBER

RATE

PER 100

TREATED

Total Cases

3,791 100'

82 2.2

(1) Afebrile cases, total

1,871 49

7 0.4

a. Evacuated on admission

b. Evacuated 2nd day or later -

1,294 34

338 15

5 0.3

2 0.6

(2) Febrile cases, total

1,920 51

75 3.9

a. Uncomplicated : —

1,791 100

31 1.7

i. Active treatment _ _

ii. Expectant :

active after fever dropped
active before fever dropped

iii. Conservative treatment -

1,069 60

521 29

22,0 12

301 17

201 11

23 2.2

8 1.6

2 0.9

6 2.0

0 —

b. Complicated

129

44 34.1

TREATMENT OP ABORTION

165

with parametritis and 10 with salpingitis; and in the 44 fatal cases,
death was due to peritonitis 23 times, to septicemia 11 times and to
embolism 4 times.

Harbitz considers that his experiences justify expectant conserva¬
tive treatment in all septic cases.

Denmark. — Grann-Petersen treated 1,118 actively out of 1,146 abor¬
tions with 5 deaths, a rate of 0.4 per cent, as compared with 2 deaths
in 28 cases treated conservatively, a rate of 7 per cent. He had 747
afebrile cases without a death, and favors active treatment.

Germany. — From Karlsruhe, in 1925, Becker reported on 1,785 abor¬
tions, showing among 1,524 afebrile cases a morbidity rate of 1.9 and
a mortality of 0.2 per cent ; as compared with 261 febrile cases where
the morbidity rate was 15.3 and the mortality 5.7 per cent. Becker
advocates active treatment of febrile abortion, since the mortality
following this method was only 2.8 per cent or less than half of the
total febrile rate.

From Nuremberg, Bund analyzes 513 abortions, 342 of which were
afebrile, and 90 per cent of these were treated actively with no deaths.
Of 171 febrile cases, 77 per cent were treated actively, with 14 deaths
(18.1 per cent) .

Berlin. From Gitschiner Hospital, Sternberg reports an experience
of 2,617 abortions showing 1,164 septic cases with 88 deaths (8 per
cent), of whom 54 died within one to four days without active treat¬
ment (complicated cases) ; and 16 others (also complicated) were
curetted. This left 18 uncomplicated fatal cases, a mortality of 1.54
per cent. Out of 1,453 afebrile abortions there were no deaths; only
39 cases had fever for one to three days. In the afebrile cases it was
possible to get along without any treatment 208 times (14.4 per cent),
and in 72 instances pregnancy was preserved.

From Moabit Hospital, Joseph and Sachs report 242 febrile abor¬
tions out of a total of 939, of which number 202 were treated actively
with 1 per cent mortality, and 40 by expectant-conservative measures
with 5 per cent mortality.

Vierneisel from Leipzig also finds a higher mortality from conserva¬
tive measures since out of 3,020 febrile abortions there were 2,613
treated actively with 33 deaths (1.3 per cent) compared with 407
treated conservatively with 15 deaths (3.6 per cent).

In Kiel (1923-1931) there were 473 incomplete febrile abortions. Ac¬
cording to Schroeder and Clauberg, 76 of these were complicated cases
in which, on account of hemorrhage, instrumental or digital removal
became necessary 18 times. Twenty-seven deaths resulted in this group.
Eliminating these complicated cases, we find 397 febrile abortions of

166

ABORTION

which 259 were ended by medication in three days (65 per cent) ; 46
had to be emptied in the presence of fever with four deaths resulting;
52 were emptied after the cessation of fever on the fourth day.

An increased mortality was noted by Englert in Munich where
treatment was delayed in cases of incomplete febrile abortions. If the
uterus was emptied within three days, the mortality was 1 out of 152
(0.6 per cent) ; if over three days, it was 3 out of 206 (1.4 per cent) ;
if a longer time had elapsed, it rose to 4 out of 148 (2.5 per cent) ; if
previously treated but incompletely emptied, 5 per cent mortality ; in
neglected cases, 12 per cent mortality. Englert rs figures are based on
the treatment of 745 incomplete febrile abortions.

M. Gerstmann from Breslau (1912-1921) employs the statistical
method suggested by Dietrich according to which all cases of infec¬
tion beyond the uterus are excluded from comparison, since here there
can be no question between active and conservative treatment. His
figures comprise a total of 1,434 abortions as shown in Table IV. From
this Gerstmann concludes that active treatment gives the best results.

Table IV

Abortion Treatment and Results (Breslau, 1912-1921)
(From Gerstmann: Ztschr. f. Geburtsli. u. Gynak. 68: 228, 1925.)

ABORTION :

NATURE

AND

TREATMENT

(1)

(2) (3)

CASES TREATED AND

(4)

RESULTS

TOTAL

CURED

WITH

MORTALITY

MORBIDITY

NUMBER

PER CENT

Total Cases

1,434

1,329

Afebrile

592

583

O’

Febrile

Treatment :

842

746

Active

614

577

Expectant _

Conservative

179

122

Griinstein in Hamburg during the same period (1912-1921) reported
297 uncomplicated febrile abortions with the following results :

CASES

MORBIDITY

MORTALITY

Active Treatment

200

(12 hospital days)

Conservative Treatment

(14 hospital days)

Expectant Treatment

Ilis conclusions are directly opposite to those of Gerstmann.

Kottlors’ experience in two and a half years with active treatment

TREATMENT OF ABORTION

167

of abortion comprises 468 abortions, 366 of which were clean cases
with no complications and no mortality ; and 92 were septic cases, one
of which had complications resulting from treatment, and no deaths.

Finland. — In Viborg, Pelkonen studied 378 febrile abortions of which
330 were treated actively and 48 were treated expectantly with a mor¬
tality of 2.1 per cent.

Russia. — Mgalobeli (Tiflis) prefers active treatment because it
shortens the period of hospitalization. Among 1,050 abortions, 101
patients had fever with a temperature over 38° of whom one died.

Kasanskij reported that one-third of 4,450 abortions in his series
were febrile, that 94.2 per cent were emptied instrumentally within
24 hours; 4.3 per cent were emptied digitally; and 1.5 per cent were
treated conservatively (cases with complications?). The curetted
cases showed 0.6 per cent mortality for the afebrile and 1.8 per cent
for the febrile group. The digitally emptied cases showed 8.9 per
cent mortality for the afebrile and 12.5 per cent for the febrile group.
The conservatively treated cases had a mortality of 14.6 per cent for
afebrile abortions and 27.3 per cent for the febrile group.

Poland. — Afebrile abortions and febrile abortions without compli¬
cations were treated alike by Grzankowsky and Kozlowski in Warsaw.
Curettage was done only in the early afebrile cases. Of 247 such abor¬
tions, only one died ; of 977 abortions treated by digital removal, 31 died
(3.15 per cent).

From the Cracow clinic Niewola gave the following figures: The

CASES

MORBIDITY

MORTALITY

Afebrile

4G5

0.6

Uncomplicated febrile

225

1.7

9 9

Complicated febrile

15.6

S.5

arguments favoring active treatment are supported by Chetmecki
from the Warsaw University clinic. Comparing the active treatment
employed from 1921-1922 with the conservative treatment of the years
1923-1926, he found that in the former group there was only one death
(0.5 per cent) out of 179 cases with 2 complications (1.1 per cent),
whereas in the latter group of 637 abortions, of which 139 were
treated conservatively, there were 7 deaths (1.1 per cent) with com¬
plications in 18 (3 per cent).

Hungary. — Out of 1,394 abortions in Budapest from 1918-1922,
Ilegedius selected the 416 febrile cases for special study. This showed
that the 233 cases treated actively had a mortality of 1.2 per cent, a
morbidity of 20 per cent, and an average hospitalization of 9.5 days,
whereas the 183 cases treated expectantly had a mortality of 1.6 per

168

ABORTION

cent, a morbidity of only 9 per cent and an average hospitalization
of 11 days. The lower morbidity makes him favor expectant treat¬
ment.

Kubinyi’s statistics cover 550 abortions. Of these 78 per cent were
afebrile with 1 per cent mortality and 22 per cent were febrile with
5 per cent mortality.

Schnerger found that active treatment shortened the hospital stay,
which is of vital importance in the working classes. In febrile cases
active treatment was delayed for one to six days after the tempera¬
ture had reached normal. His report is based on 816 cases.

Italy. — Out of 1,272 abortions in Livorno , Paci found that 106 ended
spontaneously and 1,166 required instrumental aid. Out of 216 febrile
eases six died (3 per cent).

Since Coggi treated his more serious cases of abortion conserva¬
tively, he does not feel that it is fair to compare the 26.17 per cent
mortality of 42 cases treated conservatively with the 1.79 per cent
mortality of 558 cases treated actively.

Clauser {Padua) stressed diminished blood loss in cases treated
actively. Out of 526 abortions treated actively there were 262 afebrile
cases without mortality and 264 febrile cases with 2 deaths (0.75 per
cent). Only in cases of peritonitis or septicemia does he favor con¬
servative measures.

Canada. — W. B. Hendry, studying 542 abortions at Toronto in the
years 1925-1929 found a mortality of 1.8 per cent. He preferred the
sharp curette to either the dull curette or use of the finger.

United States. — In Chicago , Hillis analyzed 1,000 abortions at the
Cook County Hospital (1920-1923). Twenty-two per cent of these cases
were induced. Owing to the difficulty of distinguishing between in¬
duced febrile cases and febrile cases with positive evidence of infec¬
tion, he preferred to treat conservatively all cases that ran a tem¬
perature. He found that if evacuation was delayed until 5 days after
the temperature reached normal, there was less subsequent morbidity.
Where the delay was less than five days, only 5 out of 12 (41.7 per
cent) had no further fever, while in 36 out of 59 cases (61 per cent)
where the full 5-day delay was maintained there was no return of
fever. Out of the 20 deaths in this series of 1,000 cases, 16 were def¬
initely criminally induced and 14 had positive involvement beyond the
uterus on admission. Only 3 out of 20 fatal cases were curetted.

W. O. Johnson sums up a two-year experience with abortions at the
City Hospital of Louisville . Out of 288 incomplete abortions, there
were 3 deaths (1.1 per cent), two from septicemia. Conservative treat¬
ment was adopted in 90 per cent of the cases, since in about one-half

TREATMENT OP ABORTION

169

of the abortions there was some rise of temperature on admission, and
21.8 per cent stated that the abortion was induced.

From 1927-1931 R. E. Watkins in Oregon observed 341 abortions, of
which only 169 were spontaneous. Of the 149 induced cases, 108 were
done by the patient and 41 by an abortionist. He divided the 307
febrile cases (90 per cent of the total group) into 193 with fever less
than 100.6 degrees, and 114 with fever higher than this. There were
only two deaths, both in the latter group of cases. Conservative treat¬
ment was employed except in 36 patients where hemorrhage neces¬
sitated intervention.

Witherspoon selected 200 cases of definitely septic abortions out of
2,253 total abortions at the Charity Hospital of New Orleans. The tem¬
perature in all these cases was over 101.5 degrees and the average of
the series was 103 degrees. Out of these 200 cases, 100 had been treated
by operation, and 100 treated conservatively. Of the 100 operated
cases, 64 were rendered more septic by the operation and 9 died. In
19 patients no indication for the operation was apparent. Of the 9
operative deaths, 6 were due to perforation of the uterus. The 100
conservatively treated cases showed no deaths, fewer complications
and a shorter period of convalescence.

Statistical Fallacies

Difficulties in drawing conclusions from many of these clinical
records lie partly in the small number of cases reported. Even when
several hundred septic abortions are analyzed conclusions are inde¬
terminate, as shown in the following record from Latzkors clinic in
Vienna :

TREATMENT

YEAR

CASES

DEATHS

PER CENT

Active :

1911

239

18.5

1913

206

2.0

Expectant

1915

182

6.0

1918

206

12.0

If 1911 and 1915 are compared, expectant treatment would appear
three times safer; but if 1913 and 1918 are compared, it would appear
to be only one-sixth as safe. Only the tabulation of approximately
1,000 cases justifies any definite conclusions, and if this number is
again subdivided into groups, we cannot be positive in our statements
concerning such groups.

On the other hand, the conclusions drawn from large collective
statistics are equally subject to criticism because of the lack of uni¬
formity in the clinical records from the various hospitals. Winter at-

170

ABORTION

tempted such a compilation from about 24,000 abortions, from which
only about one-third could be utilized, with the following results:
6,512 actively treated septic abortions had a mortality of 2.9 per cent;
1,048 conservatively treated septic abortions had a mortality of 1 per
cent; and 792 expectantly treated septic abortions had a mortality of
1.1 per cent. But Winter did not include any complicated septic cases
in his groups.

Dietrich draws his conclusions from 10,000 septic cases from 20
clinics without the elimination of the complicated cases, grouping ex¬
pectant and conservatively treated together. This showed:

mortality

PER CENT

(a) Cases with temperature over 38° (100° F.)

(1) Actively treated cases including complications treated conservatively 4.8

(2) Expectantly treated cases including those treated conservatively - 3.1

(b) Cases with temperature over 37.1° (98.6° F.)

(1) Actively treated cases including complications treated conservatively 2.1

(2) Expectantly treated cases including those treated conservatively - 1.6

These figures point to somewhat better results from expectant treat¬
ment than from active treatment. The difference is not so pronounced
but that an additional 10,000 cases might reverse the figures. It must
also be borne in mind that hospital figures include a higher percentage
of serious cases than if dispensary and home cases were included.
Active treatment is of necessity more often employed if patients are
not hospitalized.

Clearly nothing conclusive is to be hoped for from a mere numeri¬
cal calculation on the basis of reports derived from different coun¬
tries and hospitals, in which varieties of methods of treating abortion
are employed, and various ways of accounting for results. The statis¬
tics for the most part are suggestive merely, and cannot be applied to
any given case where the variables are numerous.

The question at issue , as I see it, is not whether active treatment is
preferable to expectant or conservative treatment but when active treat¬
ment is preferable and when expectant or conservative measures should
be employed.

Treatment of Uninfected and Afebrile Abortion

Complete Abortion. — The chapter on diagnosis stressed some of the
difficulties in determining whether an abortion has been completed.
When there is doubt, some assume that it is incomplete and proceed
with active measures ; others, assuming that it is complete, adopt ex¬
pectant measures. Which to pursue should depend largely on ex¬
ternal factors such as economic and home conditions and accessibility

TREATMENT OF ABORTION

171

to hospital. Where it is important that the patient assume her house¬
hold duties promptly, curettage in a neighboring hospital has advan¬
tages. If a few days of waiting would make no difference to the
patient, we can readily wait for the appearance of symptoms that
necessitate intervention.

Vogt considers the absence of bleeding and uterine cramps as a
good index that the abortion is complete. I have found that if the
giving of ergot produces increased bleeding and colicky pains it is
usually a sign that some material is still retained in the uterus.
Rouville and Madon advise a cnrettement in every early abortion
owing to the difficulty of determining whether material is still re¬
tained and because of the danger of bleeding and infection from such
remnants. If the patient has aborted in a hospital, such additional oper¬
ative work may at times be condoned, but in general every unneces¬
sary operation, even if relatively a minor procedure, should be avoided.

In the post-abortal care of complete abortion, or of abortions that have
been completed artificially, Ave must advise a hospitalization with rest
in bed from 5 to 10 days depending upon the period of gestation in
which the abortion occurs. If the abortion takes place between the
fourth and sixth month inclusive, a longer convalescence will be re¬
quired and the post-abortal care will not differ greatly from the post¬
partum care following premature labor. The breasts usually fill Avitli
secretion on the third or fourth day. They must be tightly strapped,
and ice-bags applied if the congestion becomes painful or persists an
undue length of time. Since subinvolution is more apt to follow abor¬
tion than full-term delivery, the routine administration of ergot is
recommended.

The amount of rest required after abortion varies with the compli¬
cation attending the emptying of the uterus. If there is the slightest
suspicion of a latent infection, Ave must be cautious about getting the
patient out of bed too soon for fear of a phlebitis. It is amazing Iioav
many women “get by” with no period of rest at all. If the abortion
is produced by curettement in the first two months, some patients
will proceed uninterruptedly with their daily tasks. In Russia, oav-
ing to insufficient number of hospital beds, a routine of only three
days rest is prescribed with but feAv untoward consequences. Never¬
theless this should not be our aim. Rather should Ave keep in mind
that one of the most common causes of chronic invalidism after abor¬
tion is insufficient care and rest in the after-treatment. I personally
prefer to keep patients in bed a minimum of six or seA7en days and
hospitalized for from eight to ten days after the uterus has been fully
evacuated.

172

ABORTION

Inevitable Abortion. — If the abortion can no longer be averted, our
object must be to hasten its conclusion. Usually the cervix will be
partially open at this time and undue delay might very well result in
the entrance of vaginal organisms into the uterine cavity with result¬
ing infection. Continued bleeding also makes the termination of the
abortion a thing to be desired. In what way and when to assist the
natural forces that proceed to the expulsion of the ovisac is a matter
that requires deliberation. If the abortion occurs in the second tri¬
mester of pregnancy and the ovisac is intact, we should adopt a wait¬
ing policy, merely giving medicines to stimulate uterine contractions.
Even in less advanced gestations, there is rarely need for undue
hurry, and many cases can be terminated spontaneously by simple
means. Of these simple means an ice-cap over the abdomen to stimu¬
late contractions and an enema given as warm as the patient will
tolerate it, often suffices to complete the abortion. Since in nullip-
arous women the vaginal introitus sometimes holds back an ovisac
that has been fully extruded from the uterus, it is well to let the
woman sit up and bear down; or to try to determine this fact by
rectal palpation, and exert pressure from above to promote expulsion.

Medication to stimulate uterine contractions consists of quinine,
pituitary extract and ergot. While such medical treatment is particu¬
larly advised in septic cases where operative interference is strongly
contraindicated, we can also use it to advantage in afebrile cases.

Quinine can be given in fairly large doses by mouth. Poschacher
gives 4-grains every four hours with good results. In incipient abor¬
tion this resulted in spontaneous evacuation in 82 per cent of the
cases. Strakosch gives 3 grains every hour for 6 to 8 doses. Heyne-
mann believes that a total dose of 18 grains should be the maximum.

Since many patients have an idiosyncrasy to quinine with erup¬
tions or pronounced ear symptoms, I would advise giving smaller
doses often and stopping medication at 10 grains if there is tinnitus
aurium. Some patients do not tolerate quinine well by mouth, but
the administration of this drug intramuscularly or intravenously is
not very satisfactory.

The pituitary extracts are not very effective in stimulating uterine
contractions previous to the fourth month of gestation but can be given
up to 2 c.c. as an adjunct to quinine or ergot with considerable benefit.

Ergot when given by mouth in the form of the fluid extract will
sometimes cause a spasm of the cervico-uterine musculature that
deters rather than hastens expulsion of the ovum. While this occurs
only in a small percentage of cases, this uncertain action of ergot has
militated against its use. According to Heynemann and others the

TREATMENT OP ABORTION

173

purified alkaloid given hypodermically in the form of gynergen does
not have this disadvantage and is recommended as the strongest and
most reliable medical agent for hastening the progress of abortion.
A maximum dose of 0.5 c.c. is recommended owing to the occasional
occurrence of gangrene of the extremities when larger doses are used.
This can be repeated, however, in six hours and on subsequent days.

Within reason, therefore, spontaneous evacuation can safely be
awaited if the entire ovum, or at least the entire placenta, is still re¬
tained. Fink makes an interesting comparison between clinics adopt¬
ing such a conservative course and those employing more radical
operative procedures. Out of 500 abortions at Konigsberg, 174 ended
spontaneously, 64 of them requiring the aid of medication. The com¬
parison is shown below :

TOTAL

ABORTIONS

NUMBER

SPONTANEOUS

PER CENT

Fink (Koenigsberg)

500

174

Schmidt (Bremen)

3,600

600

Gerstmann (Breslau)

540

Ludwig (Switzerland)

187

Halban (Vienna)

4,900

270

Fink concludes that Halban could have avoided about 1,470 opera¬
tions and narcoses if he had awaited spontaneous evacuation. This,
he believes, can be done: (1) by not considering every bleeding an
indication for operation; (2) by awaiting spontaneous delivery if
both fetus and placenta are still in the uterus; (3) by not doing a
prophylactic curettage, when the abortion is complete.

To be sure, the adoption of such a waiting policy will in a few in¬
stances be followed by the development of a placental polyp requir¬
ing subsequent curettement, but in the balance against this must be
placed the many unnecessary curettements with their attending com¬
plications and tendency to the development of an atrophic endometrium.

Incomplete Afebrile Abortion. — When portions of placental tissue
are retained and no fever is present, there is general agreement that
an evacuation, either with the finger, the ovum forceps, the curette or
a combination of these three agents, should be done. In some in¬
stances the placental tissue or ovisac lies loosened from its uterine
attachment but still held by its cervical ring. Here the technique of
bimanual pressure according to Hoening or Budin may suffice to
cause its extrusion into the vagina. (See Chapter XII.) In some in¬
stances it will be simpler to introduce a speculum and catching the

174

ABORTION

portion of the placental tissue lying* in the upper vagina with one or
more sponge sticks gently release it from the grasp of the cervix.

The selection of the best method for the evacuation of the uterus in
afebrile abortions will depend upon three things:

(1) The period of gestation.

(2) The degree of dilatation of the cervix.

(3) The nature of the retained material (ovisac, placenta, placental
remnants) .

In general, active treatment to hasten the evacuation of the uterus
is to be recommended in these afebrile cases, since it definitely short¬
ens the period of convalescence. Such a saving of time and money
has definite advantages. Bleeding is also reduced in amount. A
single exception is in the case of the more advanced gestations with
intact ovum especially if the cervix is partly dilated, where medica¬
tion, as already mentioned, will usually suffice to terminate the abor¬
tion. A few days of preliminary rest is of advantage, according to
Hillis7 observations, who found that afebrile cases curetted after five
days in bed had a greater tendency to remain normal than those
curetted immediately. The greatest difference of opinion in treat¬
ment is as to the agent to be employed in evacuating the uterus.
Hendry prefers the sharp curette to the blunt curette or finger.
Clauser prefers the ovum forceps and dull curette to the finger.
Grzankowsky definitely favors the finger whenever possible, while
Sternberg prefers instruments, since less dilatation is required. Such
variations of opinion could be multiplied a hundredfold. It is un¬
doubtedly true that every one works best with those agents with
which he lias had most experience, and that there are many ways of
accomplishing the same results. Nevertheless certain cardinal prin¬
ciples are almost universally accepted :

(1) In earlier gestation where much cervical dilatation is unneces¬
sary and difficult, instrumental evacuation is preferable. Before the
third month the cervix is in danger of laceration, if stretched to ad¬
mit the finger.

(2) If in such gestations considerable material is still retained, the
ovum forceps and blunt curette are safer, whereas if only placental
remnants are retained, these can more thoroughly be removed by the
large sharp or semi-sharp curette.

(3) If gestation is somewhat more advanced, the finger is a safer
agent than instruments for loosening placental tissue, even though
ovum forceps or a sponge stick is used for its removal.

TREATMENT OF ABORTION

175

(4) In gestations beyond the third month, the finger is always to
be used as a guide, even if instruments are at times necessary as an
adjunct for removing tissue.

(5) Where the cervix needs to be dilated, in the first two months
of pregnancy, the ordinary graduated metal dilators are the simplest
and best instruments. In later gestations a gauze pack in the lower
uterine segment and cervical canal is safer and after the fourth month
a small rubber bag dilator may be required.

With these cardinal principles in mind, I have prepared an outline
for the treatment of inevitable or incomplete afebrile abortion, when¬
ever action is required. Of necessity it represents to some extent my
own personal experiences and preferences. Similar graphic outlines
have been prepared for the treatment of septic abortion and thera¬
peutic abortion. (See pages 183 and 339.) In the cases considered for
this plan of treatment it should be borne in mind that the abortion is
already in progress and that the patient is not infected.

Outline A. Active Treatment of Inevitable or Incomplete Afebrile Abortion

CONTENTS

UTERUS

First Seven Weeks

Eighth to Twelfth

W eek

Thirteenth

eighth

to Twenty-
Week

Cervix

Closed Open

Cervix

Closed Open

Cer

Closed

vix

Open

OVISAC

Metal

Ovum for-

Gauze

Ovum

Medica-

RETAINED

dilator

ceps and

pack

forceps or

tion, gauze

cation

curette

finger, or

pack, col-

both

peurynter

PLACENTA

Metal

Curette

Gauze

Ovum

Gauze

Finger

RETAINED

dilator

pack or

forceps or

pack or

and ovum

metal

finger, or

finger dila-

forceps

dilator

both

tion

PLACENTAL

Curette

Ovum f

o r c e p s and

Finger and

Ovum For

REMNANTS

curette.

Finger as

ceps

RETAINED

guide (?)

Treatment of Septic or Febrile Abortion

We have discussed some of the difficulties surrounding the diag¬
nosis of septic abortion. It is of crucial importance in the treatment
to answer as accurately as possible this question of infection. His¬
tory, clinical findings, blood counts, bacteriological tests all have their
values.

Equally serious with the question “Is there infection ?” is “Has
this infection extended beyond the limits of the uterus ?,y For in the
latter event, the warning of noli me tang ere should in almost every case
be heeded. If on bimanual examination a definite thickening in the

176

ABORTION

parametrial or adnexal regions can be felt, the assumption of an
extrauterine infection must be made. In Ileynemann’s opinion, even
definite tenderness in this region or over the abdomen justifies this
supposition. In doubtful cases a second examination a few days later
may give a definite answer. In all such cases, the principle should
be “if doubtful, don’t’7 — that is, don’t pursue any active measures of
treatment. There is general acceptance of the dictum that conservative
treatment must be employed with but few exceptions in all these extra-
uterine septic infections following abortion. In a succeeding chapter
the treatment of extrauterine infections will be fully discussed, with
the consideration of such active measures as may at times be advisable.

It is with much hesitation that I undertake the discussion of the
treatment of uncomplicated septic abortion. No matter how judicial
an attitude one wishes to take, it is necessary for the sake of clear¬
ness, and for the sake of not leaving things at loose ends, to take a
definite stand on certain points at issue. At the same time I feel as
Kottlors does, who in his discussion of the subject quotes Plato :
“ Whoever of us has chosen the better part, God alone knows!”

Active Treatment. — Three decades ago, when septic infections were
perhaps less frequent, any physician who failed to adopt active meas¬
ures in treatment was considered guilty of professional malpractice.
Even now, among the laity, there is a feeling that if portions of the
placenta are retained, and bleeding and an odorous discharge are
present, something should be done at once. Active treatment is there¬
fore the easier path to tread. The fact that after the evacuation of
the uterus, fever and bleeding often cease, also encourages the physi¬
cian to adopt such measures. A further inducement to active treat¬
ment rests upon the undeniable fact that bacteria grow more rapidly
in necrotic tissue than upon the healthy surface of the uterus. An¬
other argument raised in its favor is that by means of uterine con¬
tractions, bacteria are pressed into the open wounds made by loosen¬
ing placental pieces.

Under such conditions organisms are not infrequently found in the
blood stream and in this location present the threat of a septicemia.
Particularly if such an invasion of the blood stream is repeated does
the danger of this complication become magnified. By the removal of
this infectious material, undoubtedly such dangers are greatly re¬
duced. The control of bleeding is an added reason in favor of active
treatment. There can be no question that continued free bleeding
from the uterus is no light matter. The resulting anemia leaves the
patient in a less favorable condition to fight off any infection. Un¬
deniably, we must also face certain practical difficulties, especially in

TREATMENT OE ABORTION

177

cases treated at home, that make a waiting policy difficult to enforce.
Such in the main are the arguments favoring prompt evacuation of
the uterus.

In recent years, while there has been some swing toward conser¬
vatism in treating septic abortion, we still find a large group of gyne¬
cologists favoring active measures. Some, such as E. Kehrer, who for
a time favored conservatism, have turned again to the prompt evacu¬
ation of the uterus as preferable. A few more recent reports may be
mentioned. Clauser (Padua) emphasizes the shorter hospitalization
and lessened blood-loss attending active treatment. Even in the pres¬
ence of an admission temperature he evacuates with the ovum forceps
and curette. Grzankowsky and Kozlowski (Warsaw) curette early
febrile cases, but in gestations of the second to the fourth month, use
the finger for evacuating the uterus. Sternberg (Berlin) favors
prompt instrumental removal of placental tissue. The use of the
finger requires more dilatation, which, through the danger of cervical
injuries, more than overcomes any advantage of palpating the interior
of the uterus. Olow (Upsala) prefers immediate evacuation except
in pregnancies beyond the fifth month. Yogt (Germany) considers
active treatment better and employs the finger whenever the cervix is
open as the simpler procedure. Simon (Munich) believes that every
day7s delay adds to the danger of spreading infection and hence rec¬
ommends emptying the uterus with ovum forceps and curette at once.
Among Americans favoring active treatment are Gellhorn who ad¬
vises emptying the uterus even in the presence of fever, and Hirst,
King, Baer, and Otto Schwarz, who consider the prompt removal of
necrotic placental remnants a definite advantage to the patient. On
the other hand, J. Whitridge Williams took the position that equally
good results could be obtained by either conservative or active treat¬
ment.

Conservative or Expectant Active Treatment. — Hardly any gyne¬
cologist would recommend a strictly “hands-off’7 policy in the treat¬
ment of septic abortion. The evacuation of the uterus may be delayed
but in the presence of profuse bleeding or in the case of persistent
prolonged retention of placental tissue, no one would deny the neces¬
sity of instrumental or digital evacuation of the uterus. We can
therefore more properly speak of “conservative77 treatment as “ex¬
pectant-active77 treatment. Its advantages lie primarily in the fact
that every intrauterine manipulation carries with it the risk of inocu¬
lating open wounds with infectious organisms. Surgeons have always
maintained the principle of avoiding operation wherever possible in
the presence of active infections.

178

ABORTION

In the vast majority of intrauterine infections the need for immedi¬
ate intervention is not apparent. While bacteria may multiply, the
patient’s resistance to the infection is greatly increased as a rule by a
few days of delay, and the encapsulation of the infectious material is
furthered. The virulence of the organisms seems on the whole to be
diminished by such a waiting policy. According to Winter’s obser¬
vations streptococci were often overwhelmed by the multiplication of
other saprophytic organisms and were no longer found present in the
secretions. The bacteriemia also disappears in a short time and the
temperature gradually returns to normal. Absolute rest and limita¬
tion of examination are necessary to bring this to pass.

The infection is often not at all in the ovisac but in the cervical
wounds produced by the unskilled criminal interference, so that the
evacuation of the uterus would be of no value. Furthermore, the
universally recognized principle that all manipulations are to be
avoided in the presence of extension of the infection beyond the
uterus, would make a few days of delay an added advantage. It has
been repeatedly found that only by longer observation of the case
can we with certainty exclude the possibility of such a complication.
Those favoring expectant treatment claim that the dangers of severe
hemorrhage have been exaggerated, for this accident is of rare oc¬
currence. The value of bacteriological examinations as already dis¬
cussed is undeniable, even though they should not entirely control our
method of treatment. To obtain this information will, however, re¬
quire several days for the growth of cultures. At the end of that time
the question of active interference can be reconsidered with definite
advantages to the patient.

In the experience of Martins (Goettingen) if the cervix is not yet
dilated, conservative delay to await a drop in the fever will do no
harm, and the cervix in the meantime may dilate. After a few days,
gentle instrumental evacuation can safely be performed. In abortions
after the third month the finger should be used to control placental
removal. He advises that finger and instruments be used alternately
in removing the placenta and not side by side. Never should the
sharp curette be employed. According to Offermann (Konigsberg)
active treatment is definitely more dangerous than conservative or
expectant treatment especially where criminal interference is strongly
suspected. Singer (Hungary) employs ice-cap, medication and tam¬
pons as necessary, for 3 to 5 days; then empties with a dull curette,
or, in more advanced pregnancies, with the finger. Kirstein (Ger¬
many) found that the average hospitalization of uncuretted cases was
15.4 days compared with 17.5 days where immediate curettement was

TREATMENT OF ABORTION

179

done. Yon Franque emphasizes the fact that we can safely wait five
days before interfering. He prefers however not to delay beyond this
time in active treatment even if hemolytic streptococci are found.
Bovin (Sweden) always waits six days after fever has ceased before
doing a curettage. lie found that in 94 per cent of his 894 incom¬
plete febrile abortions hospitalization was not necessary for more
than two weeks.

American literature contains many recent reports favoring con¬
servative treatment. Hillis (Chicago) strongly urges awaiting five
days of normal temperature in all septic abortions before emptying
the uterus. W. 0. Johnson (Louisville) waits for three days of nor¬
mal temperature before interference. Metzler (Delaware) says that
in the absence of severe hemorrhage in febrile cases, he employs ex¬
pectant treatment until the temperature has been normal for 5 to 6
days. Watkins (Portland) found that in about two-thirds of his cases
patients recovered without the necessity of invading the uterus.
Witherspoon (New Orleans) found such disastrous consequences when
active treatment was employed in septic abortion, that he urges a
waiting policy and non-operative measures whenever possible. Curtis
(Chicago) says in his “Obstetrics and Gynecology” that “in the pres¬
ence of an active infection, irrespective of its origin, curettage or other
instrumentation of the uterus must be avoided unless imperative.”
lie especially warns against the dangers of a repeated entering of the
uterine cavity, since the resistance to a spread of infection is decreased
with each manipulation. Anspach (Philadelphia) says it is difficult
to determine whether a septic case is limited to the uterus; hence he
prefers to await a normal temperature before proceeding with active
measures. Farrar (New York) recommends rest and ice-bag for five
days before curetting.

7 7

Polak in his excellent monograph “Pelvic Inflammation in Women
states (p. 80) : “Experience has taught us that any sort of trauma
to the delicate granulation wall which is confining the infection within
the uterus, opens avenues of extension, and that lateral parametritis
is a constant sequel of attempts at digital or instrumental evacuation.
It does no harm to remove sterile contents, but manipulation always
spreads infection when the content is already infected.

7 7

A few special methods of conservative treatment in septic abortion
are worthy of separate consideration.

Medical Treatment of Septic Abortion. — If the expulsion of the tis¬
sue or placenta can be completed without intrauterine manipulations,
the course of septic abortion is simplified. Kessler gives 3 grains of
quinine 5 times a day for the purpose. Ilabbe supplements a dosage

180

ABORTION

of 4 grains of quinine every half hour for four times with 1 e.c.
hypophysin hypodermically. This helps to dilate the cervix and at
times causes the expidsion of the ovum. Curettement, however, is
usually necessary where only placental remnants are retained. Tur-
enne and Irulegny (Uruguay) frequently effected spontaneous evacua¬
tion of the uterus by means of pituitary extract hypodermically.
Bruehl reports on 119 cases of infected abortion, 39 treated by quinine
alone and 80 in combination with gynergen with satisfactory results
except where smaller placental pieces were retained. Sixty-five cases
of induced or septic abortion were treated by Rovinskaja by the in¬
travenous administration of 5 c.c. of a 5 per cent solution of quinine
chloride, the same dose given intramuscularly, and 0.5 grain given
by mouth. In three cases there was no result, in 37 cases there was
complete spontaneous abortion, in 16 cases a few pieces of decidua
remained and in 10 cases the cervix was opened so that removal of
the placenta was easily accomplished. Heynemann warns against
this intravenous administration of quinine. In general it would seem
that in pregnancies after the third month if the major portion of the
ovisac is still retained, we can reasonably expect in not less than half
of the cases spontaneous expulsion of the uterine contents. This is
best accomplished by the administration of 15 grains of quinine by
mouth in addition to 1-2 c.c. of pituitary extract and 1 c.c. of ergot
in hypodermic form.

Drainage Treatment (Fig. 54). — Zangemeister ’s suggestion of gauze
drainage of the uterine cavity in infected abortion was employed by
E. Krieger with excellent results. Gentle dilatation of the cervix up
to 1 cm. if necessary, is followed by the introduction of a strip of
gauze 8 cm. in width, soaked in alcohol, through the canal to the
uterine cavity. This is renewed every 24 hours. This drain keeps the
cervix open, provides escape of secretions and stimulates the uterus
to contraction and expulsion of its contents. The average number of
times the drain is renewed is eight. Out of 128 cases of septic abortion
treated this way there was only one death (0.8 per cent), a 3 per cent
morbidity, and an average stay in the hospital of 11 days. In 51
cases placental pieces were expelled in the process of treatment. G.
Schwarz employed the same technique in 62 cases of infected abor¬
tion. In 40, nothing but the gauze drainage treatment was employed ;
there was no mortality, although in 12 hemolytic streptococci, and in
several others, hemolytic staphylococci were present. Schwartz’ aver¬
age number of drainage treatments was six, and in one case the treat¬
ment was repeated twenty times. He varied the size of the gauze

TREATMENT OP ABORTION

181

strip in accordance with the size of the cervical canal and never
employed force. The necessary stay in the hospital ranged between
15 and 20 days.

Nissen and Radmann employed the following technique in 77 cases.
Disinfection of the vagina, digital cleaning and curettement of the
uterus, irrigation with 2 to 3 liters of a fairly strong potassium per¬
manganate solution, wiping out the uterine cavity, especially the tubal
cornua with gauze and inserting a gauze drain soaked in tincture of
iodine for two to three hours. There were two deaths, one from
anemia and one from sepsis and the majority of patients could be
discharged in from 7 to 9 days.

Fig. 54. — Gauze drainag-e treatment of septic abortion. The gauze wick gently
introduced into the uterine cavity serves to keep it open and stimulates the uterus
to expel its contents.

Intrauterine douches with Carrel 7s solution were employed by
Salwen successfully in 9 febrile abortions having temperatures of
38.2°, to 40.8° C. (100.4° F. to 105° F). In America we find that Ill
and Darnall both employ alcohol-soaked gauze drains while T. K.
Brown irrigates the uterine cavity with 1-1,000 permanganate solu¬
tion, and removes with a sponge stick any loose placental pieces that
may be found, but does not follow this with drainage.

Charcoal Treatment of the Infected Uterine Cavity. — The favorable
results obtained by Benthin and Geller with the use of charcoal sticks
in cases of septic abortion have been corroborated by others, so that
a brief mention of this treatment should be made. Charcoal has long
been used in the treatment of wounds, even in olden times. Recently

182

ABORTION

the desirability of employing some agent that would act upon bacteria
by its physical rather than its chemical properties induced a trial in
septic abortion. Geller made tests of charcoal dissolved in saline
solution, serum and defibrinated blood and found that charcoal sticks
disintegrate rapidly in saline and bouillon and that if cultures of
bacteria are added, bacterial death results.

Naturally such a carbon preparation must be as pure as possible.
Nahmmacher recommends Merck’s preparation of carbo medicinalis.

The effect of the carbon is to absorb toxins, dry out the tissues, and
so produce a better defense reaction to bacterial invasion. It is
claimed that it also mechanically blocks the open sinuses and pre¬
vents a spread of the infection. Nahmmacher employs charcoal
pencils either before or after cleaning out the uterine cavity, accord¬
ing to the special conditions present. Ilis technique is to expose the
cervix with a speculum, catch the anterior lip, grasp a carbon pencil,
previously dipped in sterile water, by means of a dressing forceps,
and gently insert it beyond the internal os. According to the size of
the uterine cavity and the severity of the infection, two or three car¬
bon pencils are thus introduced. Generally one pencil, 3 cm. in length,
will suffice. In order to prevent the escape of the charcoal paste that
is thus formed, a thin strip of gauze is placed in the cervix for three
to four hours. Nahmmacher, without recording the number of his
cases, states that the temperature promptly drops and the odor of
the discharge disappears as the infection subsides.

Honig reported results in 210 cases treated with carbon pencils. Of
these 169 were febrile abortions and 9 were complicated febrile abor¬

tions. Of the former group none died and a morbidity of 3.5 per cent
was recorded. Since 6 out of the 9 complicated febrile cases died, he
considers it of no value in this group. The absence of chills or pro¬
longed fever in the septic abortions was particularly noted. R. Jetto
in Italy corroborated the good results of carbon pencils in febrile
abortion where the infection is still localized. R. Id. Carroll of Toledo,
U. S. A., writes favorably about his experiences with this method in
106 cases of abortion. He found it advantageous to empty the uterus
before inserting the carbon pencils into the uterus. Sixty-eight febrile
patients showed a morbidity rate of 8.8 per cent without any deaths.
There was a 25 per cent shorter period of convalescence.

Summary of Treatment of Septic Abortion

Though realizing the truth of the old saying “ there are many roads
that lead to Rome,” I nevertheless feel it my duty to point out the
road that I would recommend in the treatment of septic abortion.

TREATMENT OP1 ABORTION

183

(1) Tlie diagnosis of extranterine complications is of the utmost
importance ; so important that a few days of delay are preferable to
taking the wrong steps ; for under no circumstances should we employ
active treatment evacuating the uterus in the presence of an extension
of the infection beyond the uterus.

(2) The agent producing the least trauma should be chosen in
septic abortion. Hence medication in the form of quinine, pituitrin
or ergot is indicated wherever it might help, as in cases of intact
retained ovum or placenta, especially in the later months.

(3) A delay of five days in the evacuation of the uterus is almost
always possible and does not harm the patient. During this interval
many cases are terminated spontaneously and the remainder have a
better opportunity to build up resistance to the infection. The tem¬
perature will often drop to normal. It is often advisable to wait even
a few days longer.

(4) If the temperature has remained normal for three to five days,
emptying of the uterus will expedite recovery and usually do no harm.

(5) Digital removal, preferable in many cases of afebrile abortion,
is to be avoided in febrile cases, except perhaps where the major
portion of the placenta, in pregnancies of four to six months7 gesta¬
tion, is retained.

(6) Instrumental evacuation of the uterus can be safely done at
this time but the minimum traction and the minimum trauma must
be employed. Dilatation of the cervix is rarely necessary after the
period of expectant treatment has elapsed.

Outline B. Treatment of Septic Febrile Abortion
(Case considered septic if temperature above 38° C. [100° F. ] persists over 24 hours.)

CONTENTS

First Twelve Weeks

Thirteenth to

Twenty-eighth Week

UTERUS

Fever Present

Fever Ceased

1 Fever Present

Fever Ceased

OVISAC

RETAINED

Expectant

treatment

Quinine or simi¬
lar drug's

Evacuation
with ovum for¬
ceps followed
by blunt curette

Expectant
treatment
Quinine or
similar drugs

Expectant
treatment
Quinine or simi¬
lar drugs;
gauze pack if

necessary

PLACENTA

RETAINED

Expectant

treatment

Instrumental
evacuation by
ovum forceps
or blunt curette

Expectant

treatment

Digital removal
aided by ovum
forceps

PLACENTAL

REMNANTS

RETAINED

Expectant

treatment

Blunt curette

Expectant

treatment

Evacuation
with ovum for¬
ceps and blunt
curette

184

ABORTION

(7) Wiping the uterine cavity with a tincture of iodine sponge,
both before and after evacuation, reduces the chances of spreading
infection.

(8) The sharp curette should rarely be employed in febrile abortion
owing to increased danger of traumatism and risk of spreading in¬
fection.

(9) If profuse bleeding occurs, immediate evacuation of the uterus
by the gentlest possible method is indicated, and the blood loss
promptly replaced by blood transfusion.

(10) In the presence of hemolytic or anaerobic streptococci we
should advise longer delay in cleaning out the uterus and the minimum
of manipulation. In the presence of the Welch gas bacillus, however,
a hysterectomy is sometimes necessary.

CHAPTER XII

OPERATIVE TECHNIQUE

HPHE VARIOUS TECHNICAL procedures employed to interrupt
pregnancy are described under the head of Therapeutic Abortion.
Here we shall consider only those measures that may be necessary
when the abortion has already begun.

The first problem that comes up for discussion is whether to handle
such cases in the home, at the office, or in the hospital. Since the
physician must in every case of abortion strive to keep his name clear
of any suspicion of malpractice, it is naturally preferable for him to
treat every patient with this condition in a hospital, where records
are kept and the presence of nurse or interne prevents any possible
efforts at black-mailing by unscrupulous persons. It is relatively easy
for a man in city practice to carry this out, but in a very considerable
number of cases handled in country or small town practice this will
not be feasible. Here the necessary procedures will often have to be
carried out either in the doctor’s office or at the home of the patient.
Even under these conditions it would be best if the physician have
some third person such as a nurse or assistant present at the time of
the treatment. Kuhn believes that if curettement or removal of the
placental tissue is necessary the patient should be transported to the
doctor’s office where work can be done under aseptic conditions more
readily than in the home. We are, however, inclined to agree with
Eberliardt, who points out the danger of stirring up infection by
such an early transportation of patients. The risk of hemorrhage will
also be increased thereby.

Nowadays, when every country doctor or small town practitioner
must be prepared to handle obstetrical work in the home under aseptic
conditions and has ready for such an emergency the necessary sterile
articles and instruments, it should not be so difficult for him to handle
an abortion at the home of the patient. In practically every case
means will be at hand for sterilizing the necessary instruments.
Medical supply houses now have available sterile gauze in all forms
necessary for packing, and gown, gloves, safety razor, soap, alcohol
and antiseptics have been brought along. A kitchen table covered
with oilcloth, and leg holders or other simple contrivances to keep
the patient in the lithotomy position, will ordinarily serve as an
operating table, with better exposure than if the patient is handled
in bed (Fig. 55).

185

186

ABORTION

Some physicians are apt to underestimate the risk of infection in
these abortion cases. It is approximately ten times greater than at
the ordinary childbirth, since in almost every case the uterine cavity
must be invaded, whereas at childbirth this is rarely the case. The
relatively high mortality following the handling of abortion cases by
many physicians is largely due to their carelessness and ignorance of
these inherent dangers.

Fig-. 55. — Improvised kitchen table for emerg-ency treatment at home. (Redrawn from

Crossen. )

Anesthesia

Except for the simple removal of the ovisac or retained placenta hang¬
ing within the cervix and upper vagina, some analgesia or anesthesia will
ordinarily be required in abortion cases. Whether to apply local or
general anesthesia must be decided in accordance with the particular
conditions of the abortion. Owing to the increased risk of hemor¬
rhage with general anesthesia, this should be avoided whenever pos-

OPERATIVE TECHNIQUE

187

sible. In pregnancies that are advanced beyond the third month,
however, where intrauterine digital palpation and removal of pla¬
centa or ovisac are necessary, the complete relaxation of the abdomi¬
nal walls under general anesthesia greatly facilitates the necessary
manipulations and does not add materially to the risk. In most cases,
however, this will not be necessary, since ample anesthesia can be
obtained by the instillation of novocain in the broad ligaments, es¬
pecially if preceded by twilight sleep or the barbiturates (Pig. 56).
Only in the presence of infection is there a definite contraindication
to its employment, since organisms may be carried by the needle into
the neighboring broad ligament.

Fig-. 56. — Local anesthesia for abortion treatment. Instillation of novocain solu¬
tion into the base of the broad ligament. Both broad and sacro-uterine ligaments
are infiltrated in this manner. (Farr: Local Anesthesia, Lea and Febiger, 1923.)

In German literature we find many references (Gellert, Schneider,
Arndt) to the use of small quantities (10 c.c.) of a one per cent
novocain solution for local anesthesia. The usual technique employed
in this country is to inject from 2 to 4 ounces of a one-half per cent
solution of novocain with the addition of two drops of adrenalin to
the ounce. This gives much better results and is very effective in
controlling any tendency to hemorrhage. The preparation of sterile
novocain solution in ampoule form will permit of the wider use of
local anesthesia in country practice and thus considerably reduce the
risk attendant upon giving a general anesthetic in the home or office
under unfavorable conditions.

The Russian Podsorow found in treating several hundred cases that
his results were better when using larger amounts of weaker solutions
of novocain, e.g., 60 to 150 c.c. of a one-quarter to one-half per cent

188

ABORTION

solution, as compared with 10 to 30 c.c. of a one-half to one per cent
solution. In the latter cases anesthesia was longer in setting in, and
less effective.

It is important in infiltration with a local anesthetic to inject one-
fourth of the amount to be used into each broad ligament directly lateral
to the cervix at the vagino-cervical junction, and one-fourth of the
amount into each sacro-uterine ligament at the vagino-cervical junc¬
tion directly over these ligaments. This emphasis on the use of con¬
siderable quantities of novocain solution in the sacro-uterine liga¬
ments is based on the anatomical distribution of the sympathetic nerve
ganglia situated there which must be deadened in order to produce
satisfactory uterine anesthesia. A word of warning is also appropriate
at this point against the injection of novocain solutions without first
being certain by a slight to-and-fro motion of the needle that the
fluid is not being directly injected into the uterine vessels.

Technique of Dilatation

The conditions under which additional dilatation of the cervix may
prove necessary have already been discussed. The mechanical agencies
that may be employed vary in accordance with the amount of dilata¬
tion necessary. In the earlier months this may be accomplished by
means of metal graduated dilators, laminaria or intrauterine gauze
packs. The advantage of the graduated dilators lies in the fact that
such instruments are more readily sterilized and will produce dilata¬
tion in less time. The disadvantage lies in the tendency to produce
cervical tears and the increased risk of hemorrhage where the dilata¬
tion has been brought about without accompanying uterine con¬
tractions.

Laminaria tents have been very widely employed in Germany and
many other European countries but are not so popular in America.
These tents consist of pencils of sea-weed which swell up in the pres¬
ence of moisture and if placed within the cervical canal will slowly
stretch this canal to two or three times its former diameter. They
are usually made as a straight pencil but Niederehe has recommended
curved laminaria to correspond to the utero-cervical curve, thus re¬
ducing the ri$k of cervical perforation (Fig. 57). Nussbaum has
devised a similar curved laminaria with hollow center that permits
the escape of secretions of the uterus.

A number of objections have been raised to the use of laminaria
tents. If they slip out below the internal cervical ring, the canal will
be dilated without effect upon the region of the internal os. If, on
the other hand, the laminaria tent has slipped in too far, the external

OPERATIVE TECHNIQUE

189

os may be closed and interfere with the withdrawal of the tent. In
cases of rather rigid cervix the laminaria may assume an hourglass
shape with swelling above and below the constricted area causing
considerable pain and difficulty in its removal. Schmidt cites a case
in which a hysterectomy was necessary for the removal of a laminaria,
and cases are on record where after a false cervical passage had been
created in its introduction, the resulting swelling of the tent led to a
tear with perforation into the cul-de-sac.

In this country where sterile gauze for intrauterine packing is
readily obtainable, and the special instruments for packing in an
aseptic manner available and more widely used, we find that this

Fig-. 57. — Dilation of the cervix with laminaria and vaginal gauze pack. The
curved Niederehe and ordinary straight laminaria are shown side by side, and as
introduced into the cervical canal.

method of producing or increasing cervical dilatation is very popular.
Wherever intrauterine and intracervical gauze packing is employed
extreme care must be observed that in introducing it the gauze does
not come in contact with the external genitals of the patient. The
width of gauze pack employed will depend upon the amount of dilata¬
tion. It will vary from one-half to two inches in diameter depending
upon the case.

A serious objection to both the use of laminaria and gauze pack lies
in the fact that blood and other secretions are prevented from flowing
out through the cervix, and that this damming back of secretions
predisposes to infection.

190

ABORTION

Concerning- the technique of dilatation in the fourth to the sixth
month of pregnancy, where the amount of dilatation required will be
such as to permit the introduction of one or two fingers into the
uterine cavity, considerable difference of opinion still prevails. Some
German operators prefer to accomplish this by means of a special
dilator called Metroanoikter. This instrument will be seen in Fig. 58.
Schneider advises that it be left in the cervix for 6 to 18 hours before
emptying the uterus. The danger of cervical tears by its use is con¬
siderable and has prevented its more widespread employment. A
small Voorhees bag as described in the chapter under therapeutic
abortion is more suitable for such cases.

Fig. 58. — A. Schatz’ metranoikter with instrument used for introducing it into the
cervix. B. Klaar’s modification of the ovum forceps with crosspiece to limit the
depth of introduction into the uterus and so prevent grasping a portion of the uterine
wall.

Technique of Emptying the Uterus

If the retained material is lying within the grasp of the cervix and
visible within the vagina after the introduction of a speculum, it can
be grasped with an ordinary sponge forceps and readily withdrawn
(Fig. 59). If on examination of the tissues it appears unlikely that
any additional material is retained in the uterus, no further treatment
will be necessary. Since it is always desirable to avoid entering the
uterine cavity unless absolutely necessary, we can, before resorting
to instrumentation, employ the method of expressing the ovum sug¬
gested by Budin in which the uterus is caught between the vaginal
finger and the abdominal hand in a retroverted position and its con¬
tents milked out by pressure between the two hands (Fig. 60). A
wide dilatation of the cervix and a loosening of the attachment of
placenta or ovi-sac are prerequisites for the successful execution of

OPERATIVE TECHNIQUE

191

this maneuver. Under these conditions, as Budin expressed it, “the
ovum will pop out of the uterus just as a pea does out of its pod.”
Should the ovum be large it may be necessary to break it into several
pieces before expression will be possible.

A variation of this procedure suggested by Honing consists in keep¬
ing the uterus in an anteverted position and pressing with the vaginal
fingers against the anterior Avail (Fig. 61). In this position massage
of the uterus can be more effectively employed.

Fig. 59. — Removal of loosened and partly expelled ovisac from cervical canal by

means of two sponge forceps.

As analyzed in the previous chapter, the means for emptying the
uterus are the curette, the ovum forceps and the finger. The indica¬
tions for their use under varying conditions have previously been ex¬
plained. Here Ave need mention only a feAV special points of technique.

Curette. — The ordinary Sims or Recamier loop curette, either the
blunt or sharp form, is employed in curettement of abortion cases
(Fig. 62). The blunt curette Avill usually suffice to loosen and remove
the larger and more loosely attached bits of placenta (Fig. 63). At
times, hoAvever, particularly if the loop of the blunt curette is rather

192

ABORTION

small, it will pass over the placental tissue without dislodging its
attachment. For this reason I believe it better to employ a semi¬
sharp instrument such as is largely used in Russia and which has the
advantage of a dull edge as against the ordinary round loop of the
dull curette. In the matter of technique I think it well also to follow
the Russians in employing a rather large size curette with long ovoid
shape one and one-half cm. wide and three cm. long. While the in-

Fig. 60. — Budin’s method of expressing pieces of loosened retained placenta from the
uterine cavity with the uterus in a retroverted position.

troduction of such a curette requires slightly greater dilation of the
cervix up to a 22 Hanks dilator, it is much less apt to produce a
perforation of the uterus than the smaller more rounded curettes
commonly employed.

Occasionally in abortion of younger ova, up to the eighth week,
where the uterus contains very little material, mostly decidua, a large
sharp curette can be safely employed and if gently handled will more

OPERATIVE TECHNIQUE

193

completely remove all placental material without risk of carrying
away too much of the basic endometrial layer. In the handling of the
curette, gentleness should be our guiding principle. Naturally a
proper exposure of the cervix under good light and a thorough dilata¬
tion of the cervical canal is necessary for its safe use. The curette
should be held like a penholder and introduced very slowly until it
meets witli the slight resistance of the uterine wall. Since we occa-

Fig. 61. — Hoening’s method of expressing retained placental remnants from the

uterus with that organ in an anteverted position.

sionally have relaxations of the uterine wall that prevent the ready
recognition of resistance to the curette it is well to have a definite
mark upon this instrument gauged by the bimanual examination of
the patient that indicates the depth of the uterine cavity, beyond
which the curette should never be pushed. In the downward stroke
of the curette a little more pressure can be exerted since perforation
will not be caused in this direction, but with each additional stroke

194

ABORTION

of the curette the movement upward should be slow and gentle, just
as a rower feathers his oar (Fig. 64).

An ingenious contrivance in which the advantages of palpation are
combined with those of curettement is the so-called thimble curette
(Fig. 65). Described by Blond in 1927 it has been re-discovered and
pre-discovered by various other men. It is slipped on the index
finger and has a projecting scoop similar to a Chinese finger-nail with
which placental pieces are detached from the uterine wall.

Ovum Forceps.- — For the removal of large pieces of ovisac or pla¬
centa, the ovum forceps is better suited. This has been made in many
forms, one of which is shown in Fig. 58. Klaar has devised such an
ovum forceps with the addition of a T-shaped cuff that prevents the

Fig'. 62. — Use of the curette in abortion, showing- various types of instruments and
knobs to indicate the depth of introduction into the uterus.

i \

introduction of the instrument beyond a point where its grasp is just
beyond the internal os. By this means we can avoid any possible
perforation but are able to grasp loosened placental pieces lying near
the internal os. This brings up the question of handling the ovum
forceps. The not infrequent perforations of the uterus following its
employment are invariably due to bad technique. The ovum forceps
must not be used to loosen tissue from the uterine wall but only to
remove the already loosened pieces lying within the uterine cavity
(Fig. 66).

In cases of abortion up to three or four months gestation, where
the fetus and a portion of the placenta has already been expelled I
have found it of distinct advantage to employ the ordinary sponge

OPERATIVE TECHNIQUE

195

Fig. 63. — Large blunt spoon curette suitable for the removal of larger pieces of

placenta in more advanced pregnancies.

196

ABORTION

Fig-. 64. — Technique of curettement. Notice the slow and careful up stroke and the firm down stroke of the curette and the modified

curve of the shank to permit its use in various portions of the uterine cavity. (Dickinson.)

OPERATIVE TECHNIQUE

197

Fig. 65. — Blond’s thimble curette for the palpation and removal of placental
tissue from the uterus. The inner edge of the thimble has a scraping surface like a
curette. By means of the cord and ball the instrument can be kept firmly in posi¬
tion at the end of the finger. The hand is shown uncovered, although a glove
should be worn for such intrauterine manipulations.

Fig. 66. — Ovum forceps removing loosened placental fragments from the uterus.
Counter pressure by the abdominal hand over the uterus lessens the chance for
perforation.

198

ABORTION

forceps for the purpose of loosening and removing placental tissue.
Gordon in New York has made a similar recommendation. The sponge
forceps combines the advantages of a blunt curette and an ovum
forceps. It can be introduced without a great deal of cervical dilata¬
tion and when slipped into the uterine cavity can be opened up a dis¬
tance of two or two and one-half inches. By a twisting motion within
the uterine cavity, both blunt ring-like blades of the instrument pass
over the surface of the uterine cavity and loosen retained bits of
placenta. The fact that pressure is exerted at two points instead of

Fig-. 67. — Use of the sponge forceps to loosen and extract retained placenta. (Gordon:

J. A. M. A., 1924.)

at only one, as in an ordinary dull curette, reduces the chance for
perforation. After making several such sweeping movements with
the sponge forceps in the uterine cavity (Fig. 67), the instrument can
be closed and the material already loosened withdrawn. I have been
particularly well pleased with the simplicity of this technique and
its effectiveness in thoroughly emptying the uterus.

Use of Finger. — In every case of abortion at three or more months,
particularly in the woman who has had children, and whose cervix is
readily dilatable, the use of the finger is invaluable both as an aid
to the location of retained material and as a means of loosening that

OPERATIVE TECHNIQUE

199

Fig-. 68.— The finger as an aid in loosening retained placenta from its attachment
to the uterine wall. The longer middle finger is introduced into the cavity and the
abdominal hand presses down against the uterus from above, pushing the placenta
against this finger until it is detached.

200

ABORTION

material from its attachment. The carefully trained gynecologist
should have developed the sense of touch to such a degree that he
may be said to have “an eye at the end of his finger.” Even with
the covering of a rubber glove and the slightly deadening constriction
of the cervical ring, he should be able with a little training to dis¬
tinguish retained placental tissue without difficulty. Naturally this
technique is not acquired without a short period of apprenticeship,
and I would suggest that anyone who has occasion to have many of
these cases in his practice should develop the technique of palpating
the uterine cavity with his finger. In the technique of palpation it
is always important to press down upon the uterus with the other
hand over the abdomen (Fig. 68). By this means the index finger
can reach the furthermost corner of the uterine cavity provided it is
not over three and one-lialf to four inches in length. As a matter of
fact, by this maneuver the fundus of the uterus is pressed down
against the finger rather than that the finger actually is driven at
the fundus. It will at times be possible for the finger to loosen a large
piece of placenta and yet not entirely detach it from the uterine wall.
In such instances if the finger is used as a guide, and an ovum forceps
passed along side of it, the bit of placenta can be grasped by the
forceps. Under such control it is perfectly proper to use the forceps
for this purpose. The general rule, however, must be maintained that
the ovum forceps is not to be used to loosen placental tissue.

In cases from the fourth month on, with a uterine cavity of four
and one-half to six inches in length, the cervix should be more
thoroughly dilated so that two fingers instead of one can be introduced
(Fig. 69). Again we must emphasize the importance of using counter
pressure upon the uterus from above. Only by rubbing the fundus
of the uterus against the fingers can we hope successfully to detach
pieces of placenta tissue. This technical point is not sufficiently em¬
phasized in text-books. After such digital detachment of the remain¬
ing portions of the ovisac they can either be expressed by Honing’s
or Budin’s method as already described, or, if this is not successful,
they can be removed with the ovum forceps or sponge forceps.

In describing the technique of digital removal, Frietli stresses the
importance of avoiding contact with vaginal secretions before intro¬
ducing the finger into the cervix. To accomplish this, he catches the
cervix with tenaculum forceps and draws it down to the vulva ; then,
using the middle finger to retract the perineum, he exposes the cervix
sufficiently to introduce the index finger directly into the cervical
canal. Relaxing the pull of the tenaculum forceps he now proceeds
with bimanual digital loosening of retained tissue. Sellheim empha-

OPERATIVE TECHNIQUE

201

sizes the necessity of digital control in the more advanced cases. Even
in expert hands, control by instruments is far more dangerous and
less certain than control by the finger. He believes that an important
preliminary step to such digital exploration of the uterus is the giving
of an ampoule of 1 c.c. pituitrin or gynergen hypodermically, so that
the uterus is firmly contracted and that the necessary manipulations
are carried on with a minimum loss of blood.

He advises training students and practitioners in the technique of
such digital intrauterine palpation by means of a course on the
phantom. This should be made a part of the regular phantom course

Pig-, 69. — Two fingers used for removing retained placenta, when cervix is opened

widely, in pregnancies of the second trimester.

in obstetrics given at medical schools. In Figs. 69 and 70 will be seen
reproductions of the way in which the finger can be used as an aid
in the handling of abortion cases.

Technique in Complications.

Under the head of perforation and septic infection will be found
a description of the method of treating these complications. It will
suffice to give under this head a few more detailed instructions re¬
garding the handling of hemorrhage. Since a certain number of cases
of fatal bleeding are recorded, and since the blood loss, even if not

202

ABORTION

fatal, is an important factor in reducing the resistance to infection,
measures for the control of hemorrhage have considerable importance.
Not the least of these is the preliminary injection of 1 to 2 c.c. of
pituitary extract into the cervix approximately 1.5 cm. above the
external os. Dorster, who recommends this procedure, stresses the
importance of injecting this fluid into the tissue of the cervix, and
not into the canal.

The technique of a careful tamponade of the uterus will be found
in obstetrical text-books. Here we need stress only one or two points.

First, in the process of packing, the gauze should not come in con¬
tact with either the vulvar or vaginal surface, but pass directly
through the cervical canal into the uterine cavity. This can be ac¬
complished by the use of a Broadhead packer.

Second, it is important that both the size of the uterus and the
amount of dilatation of the cervix shall have been determined by a
previous bimanual examination, so that the size and length of the
gauze strips necessary for properly packing the uterus can be gauged.
Although in cases of hemorrhage it is important to act quickly, it is
well to remember that a little less speed and a little more accuracy
of application is preferable.

Third, it is important that the first layer of gauze be introduced as
high as possible into the uterine cavity, and that in introducing ad¬
ditional layers of gauze, sufficient pressure is employed lightly to com¬
press the gauze against the bleeding surfaces. Only too often the
gauze is merely packed into the cervical canal, so that bleeding con¬
tinues until the pressure of uterine contractions upon the clots forces
the gauze pack out of the cervix again, and hemorrhage is renewed.

The last step is firm tamponade of the vagina, beginning in the
posterior fornix and steadily lifting the uterus in order to drag on the
uterine arteries. A Sims blade to retract the rear wall and a nar¬
row elevator to retract the anterior wall are requisite, as no bivalve
speculum gives complete access to deep recesses.

CHAPTER XIII

NE OP THE MOST difficult problems in the whole treatment of

abortion is to determine whether or not, in a given case, the
infection has extended beyond the limits of the uterus. It is also one
of the most important questions that must be answered, for, if the
infection has become extranterine, measures for the evacuation or
treatment of the uterine cavity are usually contraindicated, since this
treatment will probably still further hasten the spread of the infection.

In their extension beyond the uterus, the infectious organisms may
follow one of three paths (Fig. 70) :

(1) They may pass along the lymphatics to the cellular tissue of
the broad ligament and pursue a subperitoneal path ;

(2) They may pass through the uterine wall, or by way of the tubes,
to the peritoneum and involve first the pelvic peritoneum and later the
general peritoneal cavity ;

(3) They may be carried along the uterine veins, producing a pelvic
thrombo-phlebitis with extension later to other veins, or become
scattered throughout the body in the form of a generalized bacteriemia
or pyemia.

Any of these three paths may lead to a diffuse exudate or, if local¬
ized, may form a definite abscess cavity. Although often a combina¬
tion of these paths may be followed, it will simplify a discussion of
the subject to treat all three separately. We shall therefore divide
our subject into :

(a) Cellulitis

(b) Peritonitis

Cellulitis

At the onset of septic infection there is set up a defense reaction
on the part of the body against the invasion of bacteria. In addition
to the development of antibodies in the blood, this defense consists
in an outpouring of leucocytes, and a fibrinous network that forms
a resisting capsule or wall through which the organisms must pene¬
trate in order to make deeper inroads upon the individual. Sometimes
this capsule is broken by the patient through a forcible movement of

203

204

ABORTION

the pelvic organs in straining, vomiting or walking. More often it is
breached by the manipulations (curettage, bimanual examination,
instrumentation) of the over-anxious physician. Thus the bacterial
invasion of the body may actually be stimulated.

Equally important with the amount and integrity of the defense
is the strength of the attack. Bacteria show marked variation in
virulence. At times their progress through the tissues of the body
seems invincible. From the wound surfaces in the uterus they make

Fig-. 70. — Spread of infection from the uterine cavity. (1) Veins. (2) Lymphatics.

( 3 ) Tubes.

their way along the lymph channels and, unless this path becomes
blocked, extend through the Avail into the loose connective tissue of
the broad ligament, the sacro-uterine ligaments and the upper para¬
vaginal tissues (Fig. 71). Where the cervix has been torn or injured,
the point of entry for the bacteria is more direct, and the invasion
of the broad ligament tissues occurs early. In fact, many a uterine
infection would remain limited were it not for the passage of bacteria
into the crevices of the cervical Avounds and thence along the lym¬
phatics to deeper structures. The parametria! exudate formed by this
inflammatory reaction encases the uterus so that, upon vaginal exami-

EXTRAUTERINE SEPTIC INFECTION

205

nation, the entire vault seems roofed over with a dense infiltration
that makes the palpation of more deeply situated structures impossi¬
ble. Wherever loose connective tissue is to be found, along the round
ligament, to all sides of the bladder and posteriorly around and be¬
hind the rectum, the bacterial invasion with its attendant outpouring
of exudate serves to compress and immobilize the pelvic organs.

For the advancing subperitoneal type of infection, a common path
is along the course of the ureter to the iliac fossa and upward extend¬
ing retroperitoneally to the perinephritie region. As a rule this form

Fig-. 71. — Extrauterine septic infection following- abortion. The connective tissue
of the broad ligaments and paravaginal area is invaded by way of the lymphatics
of the cervix and uterine body. (Bumm. )

of parametrial extension is more marked on one side, and forms a
mass readily palpable through the abdominal Avails. The iliac fossa
may be filled Avitli a dense wooden exudate and not infrequently the
process infiltrates forward beneath the abdominal wall. As an ac¬
companiment of this exudate the blocking of lymph channels produces
edema of all the neighboring organs. Whether the infection is more
likely to be on the left or the right side has been debated, but a summary
of the evidence points to about equal distribution between the tAvo.
In one-fourth to one-third of the cases the infiltration is double-sided.

206

ABORTION

Beside the symptoms of a spreading infection, we have in these
cases of pelvic cellulitis marked disturbance of urination produced by
the fixation and compression of the bladder. Pain and frequency of
urination are pronounced and if the bacteria have invaded the blad¬
der itself there is cystitis with burning and tenesmus. Perirectal
infiltration, produces pain and difficulty on defecation. Compression
of the pelvic nerve-trunks by the infiltration often gives rise to
excruciating pain radiating down the leg, and in cases of double¬
sided compression of the ureters we may have marked disturbance
of renal function.

Fig-. 72. — Parametrial exudate to the right of the uterus and a pyosalpinx to the left,

showing points in differential diagnosis.

The differential diagnosis between a parametric exudate and an in¬
flammatory swelling of the adnexa is often very difficult. In the latter
case the symptoms of peritoneal irritation (vomiting, pain, disten¬
tion) are usually more pronounced. Sigtvart states that parametritis
is more apt to be one-sided while the adnexa are more often both
involved. From below a parametrial mass will usually be more dense
and extend laterally from the cervix to the pelvic wall, presenting a
slightly concave surface to the examining finger through the vagina,
whereas the adnexal tumor will be more convex in its feel and be

EXTRAUTERINE SEPTIC INFECTION

207

partly separable from the pelvic wall (Fig. 72). Sigwart believes
that after abortion true parametritis is less common than the adnexal
swellings with surrounding exudate.

The course of pelvic cellulitis varies greatly. In general the prog¬
nosis as to life is fairly good compared with that in blood stream
infections. Some of the cases undergo complete, if rather tardy,
absorption. The majority however have a less favorable course.
There may be prolonged invalidism extending over weeks, or even
months. The patient is left will pelvic scars that distort the posi¬
tion of the organs, and produce radiating pains down the legs, dys¬
menorrhea and marked dyspareunia. Many of these women remain
partly disabled for life. In other instances the exudate softens with
the formation of an abscess, that rapidly increases in size producing
elevation of temperature to 39° C. (102° F.) or higher with pain and
pressure symptoms. A frequent site at which such an abscess points
is over Poupart’s ligament in the iliac fossa to one side or the other.
At times the abscess is more deeply situated, and owing to its thick
capsule its location may be difficult to ascertain until it breaks into
the vagina, bladder or rectum. Perforation into the rectum is the most
common and is usually preceded by the passage of quantities of blood
and mucus with the stools until the abscess bursts and quantities of
foul smelling pus are evacuated with the stools. The evacuation of
the abscess will usually be followed by permanent relief, but not al¬
ways, since the perforation is sometimes small, and the drainage
incomplete.

In the treatment of pelvic cellulitis in the acute stage, nothing is
indicated but rest, ice-caps, good elimination, a nourishing diet and
such other measures as will build up the patients resistance. All
manipulation and unnecessary examination are to be avoided. As the
process begins to subside we may start protein therapy with injections
of sterilized milk, increasing gradually from 3 c.c. to 10 c.c. at a
time, depending on the severity of the reaction produced. It is par¬
ticularly in cellulitis that such protein treatment will materially shorten
the period of convalescence. The interval between the injections is
usually three to four days. Where an elevation of temperature and
the pelvic examination point to the development of an abscess, we
must open it with due regard to the attendant risk of penetrating
the peritoneal cavity, the bladder, or the rectum in the course of this
procedure. Drainage of such an abscess must be continued until there
is no further discharge of pus and the abscess sac has been reduced

m size.

208

ABORTION

Peritonitis

Three paths of invasion may be followed by septic infection in gain¬
ing access to the peritoneal cavity after abortion. One is directly
along the wound made by some perforating instrument ; a second is
from the uterine cavity through the tube to the peritoneum • and a
third is directly through the uterine wall along the lymph spaces to
its peritoneal covering.

According to Sigwart, septic peritonitis associated with tubal in¬
fection is most often due to an abortion. Out of 69 autopsies for
peritonitis reported by Halban and Kohler, the port of entry was
found in 12 cases to be by way of the tubes; in 10 of the 12 cases
it followed an abortion, and in only 2 a full-term pregnancy.

According to Curtis, ovarian abscesses are a frequent feature of
post-abortal infection. These may attain a large size and be very
stubborn. The tubes are attacked most often from without. The
process begins as a peri-salpingitis with invasion of the tubal mucosa
last if at all. The ends of the tubes are often sealed resulting in a
hydrosalpinx, but on the other hand, sterility is less frequent than
after gonorrheal infections, even though a large pelvic abscess has
developed.

As to 'perforation peritonitis, there is great variation in severity de¬
pending on the nature of the infecting organism. In the case of
staphylococci or colon bacilli the infection may remain localized, but
in the presence of streptococci there is rapid diffusion with usually
a fatal outcome. The path through the uterine wall usually offers
considerable resistance to bacterial invasion, so that the organism that
is capable of penetrating through the interstices of the fibro-muscular
coat is certain to be a virulent one and once it attains the peritoneum
produces a severe generalized peritonitis. Practically always in these
cases we find it to be a streptococcus. It is amazing with what speed
such an infection can produce a fatal outcome. There is usually no
time for any accumulation of leucocytes, the uterine wall shows no
trace of purulent material and the peritoneal cavity shows but a
few flakes of fibrin in the serous effusion that contains myriads of
streptococci. The serous coat of the peritoneum may in these cases
still retain its glistening appearance. All in all, the peritonitis fol¬
lowing an infected gestation is a more serious condition than that
following surgical operations. Grekow reports a mortality of 53 per
cent in peritonitis following obstetrical conditions, as compared with
40 per cent mortality following appendix peritonitis. Benthin found
a mortality of 50 per cent in streptococcus infections compared with
25 per cent where staphylococci or colon bacilli were present.

EXTKAUTERINE SEPTIC INFECTION

209

Sigwart analyzes 36 cases of diffuse peritonitis recently treated in
his clinic. Of these 20 followed abortion and only one followed full-
term delivery. Of the remaining 15 cases, 9 complicated gynecologic
operations and 6 were due to an appendicitis. Of the 20 cases of
abortion peritonitis, 13 died, S women being almost moribund on
admission, and the remainder dying in spite of operation. Only 4
of the 9 gynecologic cases died, and but one of the 6 appendix cases.

The fact that in abortion the septic organism is introduced from
without, leaving no time for defense reaction by the body, is doubtless
an important factor in the high mortality. There is also a lowered
resistance to infection in pregnant women, as we have had occasion
to notice in the high mortality from peritonitis in women who have
had a grippe pneumonia. Where the septic peritonitis is associated
with a blood-stream infection as well, the outcome is fatal almost witli-
out exception.

Occasionally the peritonitis becomes localized and may then form
a definite abscess usually pointing in the cul-de-sac. This is a more
favorable type although such a case may suddenly take a turn for
the worse and the infection spread to the general peritoneal cavity.
Sigwart reports nine such cases, eight of them following abortion, nil
of whom recovered following incision of the cul-de-sac (Figs. 73-76).

The clinical picture of septic peritonitis is usually well defined.
There is severe abdominal pain, often double-sided with marked
tenderness to pressure, rigidity of lower abdominal muscles, rapid pulse
and prostration. At the onset it may be hard to decide whether the
process is localized or already is making its advance to the general
peritoneal cavity. On the appearance of hiccoughing and vomiting
with tympanites and distention there can no longer be question of
the diffusion of the infection Rapid pulse and dry tongue are bad
prognostic signs. The tenderness over the abdomen soon becomes so
exquisite that even the weight of the bed clothes cannot be tolerated.
There is persistent severe colicky pain as the intestines fill with gas
which they are unable to expel. The vomiting soon assumes a fecal
character and may in the final stages consist largely of a blood-stained
material. With a rapid and feeble pulse, hurried shallow respiration,
an anxious expression, sunken eyes, pointed nose, a dry cracked
tongue, sweet-sour odor to the breath, and cold extremities, the end
is near at hand.

Occasionally the picture is not so positive and leads to error. The
absence of abdominal pain cannot exclude a peritonitis. Sigwart
finds that with a rapid pulse, nausea, a dry tongue and prostration
the infection may be widespread even though pain is not present. In

210

ABORTION

doubtful cases puncture of the abdomen is of considerable diagnostic
value, since it will give direct evidence of a serous or purulent exudate
in the peritoneal cavity. If a thin needle is employed, the risk in-

Fig. 75. Fig. 76.

Figs. 73-76. — Steps in the incision and drainage of a pelvic abscess.

Fig. 73. — Incision through the vaginal wall with posterior lip of the cervix
caught by a tenaculum forceps.

Fig. 74. — Blunt dissection of posterior vaginal connective tissue up to the abscess
by means of scissors under guidance of the finger.

Fig. 75. — Plunging through abscess wall with sharp-pointed cvxrved scissors.

Fig. 76.— -Drainage of abscess with a T-shaped rubber tube. (Crossen: Operative
Gynecology .)

EXTRAUTERINE SEPTIC INFECTION

211

volved is minimal. Even where but little material is obtained, mi¬
croscopic examination may reveal the presence of leucocytes.

Another diagnostic help is the blood picture as shown by the Schill¬
ing count described before (Fig. 53). In two instances Schilling was
able to diagnose a septic peritonitis in the absence of almost all clini¬
cal symptoms. In view of the fact that in abortion peritonitis there
are many factors stimulating cell development in the bone marrow
(pregnancy, blood loss, infection and toxemia) we find in it an unu¬
sually pronounced shifting of the blood picture to the left. Myelo¬
cytes are frequently found, especially juvenile forms ; lymphocytes
are lower than normal ; eosinophiles are absent, the stab count is high,
and the general leucocytosis as a rule is marked. We may, however,
find a normal or even markedly low leucocyte count in individuals
who show poor resistance to infection. This is usually a bad sign.
Since in early cases the operative treatment may save the patient’s
life we should arrive at a positive diagnosis as quickly as possible.

Drainage. — In the treatment of septic post-abortive peritonitis, the
value of surgical interference will depend largely on the type of in¬
fection. In the cases in which the uterine wall has been directly
penetrated by the invading organisms, it is almost invariably true
that the blood stream has also been entered and in such cases surgical
measures are without avail to save the patient. In less virulent cases
even though a diffuse peritonitis exists, we may still hope for re¬
covery if complete drainage can be established (Figs. 77-78).

Sigwart recommends a small midline incision over the symphysis,
associated with drainage openings in both flanks. To effect this he
advises that a dressing forceps be introduced through the median
incision beneath the parietal peritoneum to the flank, and the ab¬
dominal wall incised over the end of the forceps. Thereupon, a long
rubber tube with many perforations is caught by the forceps and
drawn through to the median incision. In similar manner a drain is
placed to the opposite side. A third drainage tube is placed behind
the uterus to the cul-de-sac. Before these tubes are inserted the
purulent fluid is removed as completely as possible, and from 100 to
150 c.c. of ether are poured into the abdominal cavity. After the
drains are in place, an additional 50 to 100 c.c. of ether are injected
by a syringe through the tubes, care being taken to clamp off the
lateral ends of the tubes, so that the ether does not escape too rapidly.
The use of ether in this manner in addition to drainage apparently
does no harm and in Sigwart ’s experience adds materially to the
chances of recovery.

212

ABORTION

In twelve cases of post-abortive peritonitis operated on in this way
Sigwart was able to save seven patients, making a mortality of 41
per cent. Other reports give a considerably higher operative mor¬
tality ranging from 65 to 78 per cent. Schaefer reported 75 cases of
puerperal peritonitis of whom 10 were moribund and 39 hopeless on
admission. Of the 26 remaining, 3 out of 15 patients subjected to
colpotomy recovered, and 2 out of 11 laparotomies that were drained
were saved, making a total of only 5 survivals among the 75 women.
Chydenius reported that from 1925 to 1929 there were 1,267 abortions

t5 •

Fig-. 78.

Figs. 77, 78. — Drainage treatment of acute pelvic peritonitis.

Fig. 77. Vaginal drainage of culdesac with gauze and soft rubber tubes.

Fig 78.— Abdominal drainage of pelvis through a hard rubber tube. (Crossen
Operative G-ynecology.)

with 32 cases of peritonitis. Out of 11 unoperated cases there was
but one recovery, whereas out of 21 cases subjected to laparotomy.
9 patients recovered. Simple drainage gave relatively poor results,
hence he added the removal of adnexa and uterine body, draining
vaginally through the cervix. This operation done under ether nar¬
cosis took about one hour. The first series showed 2 out of 6 re¬
coveries, which was increased to 6 out of 10 who recovered when the
sigmoid was fastened down over the drainage area in the pelvis.
Apparently many of these cases were rather mild infections. Only

EXTRAUTERINE SEPTIC INFECTION

218

3 out of 13 streptococcus peritonitis cases recovered. Mollenbeck
reported 30 cases of peritonitis following abortion with 28 per cent
mortality when the cul-de-sac was incised as against a 50 per cent
mortality in cases of laparotomy.

Thrombophlebitis and Bacteriemia (Pyemia)

The invasion of septic organisms by way of the blood stream natu¬
rally presents the most serious and fatal condition (Fig. 79). This
so-called “blood poisoning77 is often so rapidly overwhelming that

V. uterin.i

Vpna CiiV.l

V. Hiaea com-

Hium<

V, hypo-
gas trica

Plazentars telle

Thrambus a» tier Tctlungs*
-veils? tier Y. cava

- V. iiiac.1 t-ftmmunis

V, hypogast dk;.s

V, femoral®

V. spermatir i

Fig-. 79. — Septic thrombophlebitis, showing- spread along- ovarian veins on the left
side and along- the uterine veins to the vena cava on the right side. (Bumm.)

death ensues before any noticeable pathologic changes occur in the
organs. Only the blood culture and the clinical history establish the
diagnosis. These are the cases in which the blood produces no de¬
fense reaction in the form of a thrombus but serves rather as a growth
medium for the organisms. The term, septicemia , should be limited
to this group in distinction from the cases of septic thrombophlebitis
and bacteriemia in which there are at least temporary limitations to
the progress of the infection. The most common agent of this virulent
infection is the hemolytic streptococcus.

214

ABORTION

In the process of invasion from the surface of the uterine wound we
find that the necrotic material covering it contains innumerable
saprophytes, while the deeper tissues including the venous thrombi
contain usually many streptococci. It is the virulent organism that
alone possesses the faculty of penetrating deeper into the maternal
organism. In a sense, therefore, the endometrium serves as a filter
holding back the ordinary sapremic bacteria.

Warnekros considers that only streptococci and staphylococci have
the faculty of actually penetrating through the inflammatory exudate,
getting into the veins and producing a thrombophlebitis. If the blood

Fig-. 80. — Cross-section of thrombosed vein. (Bumra.) A. Wall of vein. B. Loosened
particles of thrombus. C. Liquefaction area. D. Thrombus.

culture is taken at the time of the pyemic chill these organisms will
usually be found. In 12 fatal cases of pyemia he found streptococci
9 times and staphylococci 3 times.

Occasionally other organisms may be found associated with these
cocci such as the Bacillus aerogenes capsulatus, the bacterium coli and
Welch’s gas bacillus (Fraenkers Bacillus emphysematosus) .

Whether in a given case there will be a spreading thrombosis or a
purulent degeneration of the thrombus depends primarily on the
virulence of the organism. In the less virulent cases there may be an
encapsulated intravenous abscess (Fig. 80). I had occasion to operate

EXTRAUTERINE SEPTIC INFECTION

215

on sucli an encapsulated abscess, situated in the internal iliac vein,
that presented a mass the thickness of a thumb and had been mistaken
for an adnexal swelling* (Figs. 81-82). This patient gave a history of
an infected abortion three years previous co this operation.

While the thrombophlebitic process may be localized to one side it
is quite common to find some involvement of the opposite side as well.
The spread will be influenced somewhat by the location of the pla¬
cental site. If the placenta is situated at the fundus the thrombosis
will spread first to the ovarian veins, whereas a lower situation of

Fig, 81. — Low power section of a thrombosed ovarian vein with abscess formation
following septic abortion ; removed by laparatomy four months later. The walls of
the vein are outlined by the elastic tissue stain. In the lumen of the vein can be
seen clumps of pus cells.

the placenta predisposes to extension in the broad ligament veins. In
the 82 autopsies for pyemia reported by Ilalban and Kohler the
thrombosis occurred twice in the uterine veins (Fig. 83), 14 times in
the parametria! venous plexus, 19 times in the ovarian veins, 4 times
in the venae cavae and 31 times in various combinations of these veins.

Diagnosis. — The whole problem of the prognosis and treatment of
this most serious condition is primarily influenced by difficulties in
diagnosis ; not merely difficulties in determining whether a throm-

216

ABORTION

boplilebitic process has taken place, but also difficulties in ascertaining
the extent and multiplicity of the thrombi. Another complicating
factor is that in one fifth of the eases of thrombophlebitis, according
to Ilalban and Kohler, there is a simultaneous periphlebitis.

The diagnosis of a thrombophlebitis is usually based upon the oc¬
currence of a sudden chill with elevation of temperature in a patient
whose uterus has been previously emptied spontaneously or artifi¬
cially. This is followed by an equally sudden drop in temperature,
with cessation of the symptoms of prostration that accompanied the

Fig-. 82. — High power section of a portion of vein seen in Fig. 81. Note the
organized thrombus infiltrated with leucocytes. Elastic tissue of vein Avails is stained
black.

fever. After a shorter or longer interval the chill and prostration
may be repeated. Between the chills the temperature and pulse re¬
main slightly elevated but the patient feels fairly comfortable. The
course of the disease may vary from half a day to many months in
duration. To make the diagnosis from the appearance of the first
chill will lead to many mistakes since the absorption of fetid material
from the uterine cavity will at times give rise to a very similar pic¬
ture. In searching for other diagnostic signs emphasis is laid upon
the palpation of thrombi in the broad ligament on vaginal examina-

EXTRAUTERINE SEPTIC INFECTION

217

tion. The thrombosed veins in the broad ligament will usually feel
like earth-worms with occasionally a thicker strand of exudate sur¬
rounding it. Martens also claims that the thrombosed ovarian veins
can be palpated through the abdomen over the brim of the pelvis.
The certainty of the palpatory findings will vary in accordance with
the case, but if present, such findings are an important auxiliary in

Fig. 83. — Streptococcic infection following abortion. Section of septic thrombus in

wall of uterus obtained at autopsy.

the diagnosis. Stoeckel denies the possibility of recognizing thrombosis
of the ovarian veins by abdominal palpitation.

In recent years the blood picture has been stressed as a diagnostic
sign. In addition to a marked shift to the left in the Schilling count,
Kriele pointed out that in the initial stage of a thrombophlebitis or
pyemia we have a striking thrombopenia. Normally there are about
250,000 blood-platelets (thrombocytes) to the cubic centimeter of

218

ABORTION

blood. In cases of pyemia there is a drop far under 120,000. If the
count of thrombocytes is not under 120,000 and there is only a slight
lowering of the leucocyte count, the prognosis is good and the pa¬
tient probably will recover. On the other hand, if the blood-platelets
are reduced to the neighborhood of 60,000, Kriele considers the infec¬
tion probably fatal. Thus far Kriele ’s observations have not received
a careful check-up but they present a possible early prognostic sign
of great value.

Prognosis. — Predicting the outcome of a pyemia presents many

difficulties. There may be but one chill and no more. On the other

hand, the chills may be repeated as many as 28 times, and still be
followed by recovery. On the other side of the picture, Hannes cites
a case in which there was a sudden chill on the seventh day post-
abortum followed by a temperature rise to 41.6° C. (106.5° F) and
death within six hours. The mortality figures given by Schroeder
showed 92 cases of thrombophlebitis with 32 deaths. This, however,
did not include 36 hopeless cases who died shortly after admission.
Adding these Ave would have 68 deaths out of 128 post-abortive cases
of thrombophlebitis. The analysis of Schroeder ’s cases showed the
difficulty of setting the prognosis at the time of the first chill. The
number of chills vary greatly, up to 49 in the fatal cases and up to
18 in the cured cases. It was nevertheless striking that with the
elimination of the 36 hopeless cases 65 per cent of the remaining 92
Avere cured spontaneously without special intravenous treatment or
ligation of veins. A somewhat similar report comes from K. Tietze
and IT. Plaue in which 141 cases are included, of Avhom 57 Avere post-
abortive pyemias with 29 deaths or 51 per cent mortality. Of the
remaining 28 post-abortive cases that recovered, 8 Avere serious, 4
moderately serious and 16 were light cases. Out of 5 patients in whom
ligation of the veins was done for the pyemia, 4 died. In view of the
relatively high percentage of spontaneous recovery (50 per cent) the
authors question the advisability of other forms of treatment.

Ligation. — The question of whether to ligate the veins in these cases
of thrombophlebitis has in the past feAv years become a very crucial
one. Opposing the conservative vieAvs of most leading gynecologists,
Max Martens and a few of his folloAvers have proclaimed the value
of ligation and supported their contentions Avith a considerable amount
of clinical experience. Although the suggestion to ligate the veins
in cases of infection had been made by various surgeons in the 19th
century, it remained for F. Trendelenburg in 1902 to accomplish the
first cure by this method of ligation. Since that time many surgeons
have performed this operation for varying types of infection. Mar-

EXTRAUTERINE SEPTIC INFECTION

219

tens took up the procedure systematically in post-abortive pyemia
and both by his practical experience and by his writings on the subject
has become the chief protagonist of this method of treatment. Ac¬
cording to Martens there is a general agreement that a septic throm¬
bophlebitis requires ligation of veins to limit the infection. The various
injections of antiseptic agents intravenously (rivanol, elektro-kollar-
gol, argochrom, methelene-blue-silver, yatren) he states are of no avail.
It is also false to claim that most pyemias heal spontaneously. Early
ligation of the veins is alone effective. The claim by Herff that “each
chill may be the last one” leads to dangerous procrastination. The
ideal, according to Martens, would be to ligate before the first chill,
for even the first chill may lead to a fatal metastasis of the infection.
From the yearly average of 3,000 to 4,000 deaths from puerperal sepsis
n Germany lie figures approximately 1,500 to 2,000 cases of septic
thrombophlebitis, in very few of which ligation of the veins has taken
place. From Martens’ personal results, 19 cures out of 29 operative
cases (about 60 per cent), he figures that approximately 1,200 of these
women could have been saved annually by ligation. Martens quotes
Hinselmann as saying that whoever does not use this method of liga¬
tion has never tried it or has done so at the wrong time or in the wrong
way. Schaefer rs experiences corroborated to a considerable degree
those of Martens. Only one out of 17 pyemias was spontaneously
cured, 7 were cured following ligation, the remainder died. Sultan
reported 3 cures out of 7 operated cases. The 4 fatal cases had ex¬
tensive septic metastasis before operation.

In America, Huggins published 12 cases of ligation of veins with
6 deaths. He groups the cases into light, moderate and severe infec¬
tions. In the light infection spontaneous cure will often result, in the
severe infections the outlook is usually hopeless, hence he would re¬
strict vein ligation to the moderately severe cases in whom the process
after eight to ten days begins to become chronic but the general con¬
dition of the patient still remains good. An attempt to compile mor¬
tality figures was recently made by Hannes who reported 55 cures out
of 111 operations, approximately 50 per cent. This compared with
the figures compiled from previous reports by Sigwart of 48 per cent
mortality in 208 cases and PolakTs reported mortality of 52 per cent
from 182 vein ligations, largely from American literature.

The conclusion is inevitable that with vein ligation not over one-
half of the cases can be saved. This is far from encouraging. Against
ligation the arguments raised are: (1) an extension of the thrombus
beyond the ligature ; (2) an extension along veins that were not ligated ;
(3) the danger of the operation itself; (4) the fact that the indication

220

ABORTION

Fig. 84. Fig. 85.

Figs. 84, 85. — Excision of thrombosed ovarian vein by transperitoneal abdominal
operation.

Fig. 84. — Ligature placed above point of thrombosis including artery and vein.

Fig. 85. — After ligation the vessels are removed with tube and ovary of same
side. (Crossen: Operative Gynecology.)

upon a further check-up of Kriele’s thrombocyte count. Should this
blood test give us dependable information, operative interference
could be gauged more accurately. For the present, we do not feel
that the operation of vein ligation can be generally accepted as the
proper treatment for all cases of pyemia. Technically, the operation

for operation often cannot be set until too late. One cannot get away
from the fact that the early operation recommended by Martens brings
with it not merely the frequent reproach of having done an unneces¬
sary operation, but also raises the question whether the operation may
not actually have done the patient harm. The possibility of an early
correct diagnosis of the thrombophlebitis may depend a good deal

EXTRAUTERINE SEPTIC INFECTION

221

presents many difficulties, and probably more harm than good would
be accomplished except in the hands of a few well-trained and judi¬
cious gynecologists.

In the matter of technique a heavy silk is usually employed to prevent
cutting through of the ligature. Only in the cases of the ovarian, is
the removal of the diseased vein ever performed (Figs, 84-85). The
ligation should always be done sufficiently high; if necessary', up to
the vena cava itself. In other instances, ligation of the ovarian and
internal iliac veins will suffice. Considerable difference of opinion
has existed as to whether the transperitoneal or extra-peritoneal op¬
eration was preferable (Fig. 86). In favor of the direct incision it
has been claimed that more accurate information was quickly obtained
as to the location of the thrombi and the point necessary for ligation;

AVobf. uvt.

M ilio¬
psoas

Vena

cava

PenJorveam
V. spermahca.cl
Urete.r

A. iliac a comm..

V Kqpoqastrica.
A.hijpoqasMca.

A. iliaca . exf.

Fig-. 86. — Anatomical relations of structures exposed by Martens’ extraperitoneal
operation for pelvic thrombosis. (Redrawn from Martens.)

also the fact that, particularly in abortion cases, the diseased adnexa
can be removed at the time, if necessary. Against this method of
operation, Martens and others claim the greatly diminished shock
attending the extra-peritoneal procedure with lessened risk of post¬
operative peritonitis and ileus.

The technique of the extra-peritoneal operation recommended by
Martens is as follows: An incision four inches long is made over
McBurneyTs point, followed by separation of the internal oblique
muscle. Then the peritoneum is pushed back over the iliac fossa until
it exposes the ureter where it crosses the iliac vessels. The ovarian
vein is higher than the ureter and is ligated after isolation. Then
the internal iliac vein or common iliac or lower vena cava is isolated
in accordance with the location of the thrombus, and ligated with
heavy silk. It is better to start on the right side as the vena cava is

222

ABORTION

more accessible on that side. Always ligate above the thrombosis.
Drain parametrial infections if found. It is well to attack that side
first which seems most definitely involved. The opposite side should
be ligated, if possible, but not in every instance.

To revert for a moment to other methods of treatment of pyemia
besides ligation, we find that some men have faith in intravenous
therapy, especially mercurochrome. Curtis thinks that there has been
some improvement in the preparation of an antistreptococcus serum
and that results with it are slightly more encouraging. He is opposed
to ligation of the veins for pyemia and to hysterectomy for pelvic
sepsis. Particularly does he dread the routine curettage of infected
cases which only too often is responsible for the development of a
septic thrombophlebitis.

All in all, therefore, in this group of generalized septic infected cases
we must acknowledge the limitations of therapy at present available.
The prevention of complications is more significant than their cure
and can be best accomplished by a minimum handling of cases until
acute symptoms have begun to subside. With good judgment in
selected cases, I believe drainage of the cul-de-sac in peritonitis and
ligation of the veins in cases of pyemia of moderate severity will im¬
prove our results. Our mainstay, however, for the present still is the
building up of resistance to the infection by the patient herself and
this can best be accomplished by rest, good nursing care, a nourishing
diet, blood transfusion, and above all fresh air and sunshine. It re¬
mains for future investigators to give us an agent that will specifically
resist and overcome the inroads of the streptococcus. Only then will
we be able materially to reduce the mortality of the infections ex¬
tending beyond the limits of the uterus after septic abortion.

CHAPTER XIV

PERFORATION

IN NO COMPLICATION of abortion can a mistake in judgment or
* technique on the part of the practitioner lead to more serious re¬
sults than in accidental perforation of the uterus. Perforation is one
of those misadventures that probably occur very much more fre¬
quently than the printed records would indicate. Most of the cases
are never reported because, after all, it is usually the operator’s fault,
and not a pleasant thing to write about. You can hardly find a busy
gynecologist who will not, when questioned, tell you of at least one
such disagreeable experience. And how much more frequent must
the accident be among the rank and file of practitioners, unaccustomed
for the most part to the use of instruments, and taught for many years
that “abortion ought to be curetted.”

Perforation of the uterus or other organs, associated with abortion,
is an accident limited largely to the past fifty years during which the in¬
strumental evacuation of the uterus has become the prescribed treatment.
Spontaneous perforation of the uterus in association with abortion
is practically unheard of, except as it may in rare instances follow
the necrosis and infection of a complicating myoma.

Frequency. — With each decade of the past fifty years the actual and
proportionate frequency of this accident has increased, due, first, to
the increase in the number of instrumentally induced abortions ; sec¬
ond, to the proportionate increase in abortions handled by doctors as
against those handled by midwives ; and third, to the prevailing tend¬
ency to use instruments instead of the finger in emptying the uterus.

The frequency of perforations in the treatment of abortion has been
varyingly estimated from about one in 150 to one in 1,000 evacuations
of the uterus :

Rahm in Helsingfors reports 9 perforations out of 3,850 curettements
for abortion (0.2 per cent or 1 in 425).

Heynemann in Hamburg finds one perforation for ever 200 instru¬
mental evacuations of the uterus (0.5 per cent).

In Russia, Kakuschkin gives the incidence of perforations in in¬
strumental abortions as 0.6 per cent or one in 160. Other Russian
statistics gives figures varying from 0.2 to 0.7 per cent (1 in 800 to
1 in 140).

223

224

ABORTION

In 1932 Syrowatko (Russia) reported 22 perforations out of 21,420
legal abortions done in a period of three years. Where the doctors
regularly trained in abortion operated, the incidence was only 0.08
per cent (1 in 1,250) ; whereas in 750 abortions done by substituting
physicians there were 5 perforations, an incidence of 0.66 per cent
(1 in 150).

Halban, in Vienna, on the other hand reported that out of 6,025
curetted abortions cared for in his clinic there were only 9 cases of
perforation (0.15 per cent or 1 in 670).

If such percentages are obtained when curettements are done in
well-organized hospital clinics, we can safely assume that in the much
larger group of cases handled by the general practitioner, under far
less suitable conditions of home or office, the incidence of uterine
perforation is three or four times as great. The considerable majority
of cases cited in various reports on perforation do not originate in
the clinic but are sent in from the outside after accidental injury has
occurred.

Of special significance is the fact that in the past twenty years there
is ample evidence of the increasing number of these perforations. This
is clearly shown in the accompanying chart (Fig. 87) of figures from
the report of Herbig, in Hamburg, on the distribution of the 134 cases
coming to the clinic from 1910 to 1923. Incidence is not shown here,
as total instrumental evacuations are not given, but Heynemann’s
report (given in Table V) shows increase in both numbers and in¬
cidence.

Table V

Incidence of Perforation in Instrumental Evacuation
(Reported by Heynemann: Zentralbl. f. Gynak. 49: 1241, 1925.)

YEAR

(1) (2)

TOTAL INSTRUMENTAL

ABORTIONS EVACUATIONS

(?>)

NUMBER

(4)

perforations

PER

CENT

RATIO

ONE TO

1919

9,000 1,500

0.53

190

1921

12,000 2,000

0.35

290

1923

14,000 2,300

0.69

144

The mortality associated with perforation varies with the proportion
of outside cases coming to the clinic. In the Russian abortaria where
legalized instrumental abortions are performed under hospital condi¬
tions, a relatively small percentage of perforations end fatally, even

PERFORATION

99^

i_j ljU

when associated with severe injury and hemorrhage. On the other
hand Bumm, in Berlin, reports 4 fatalities out of 12 perforations.

Peham and Katz in their monograph on perforation record 86 deaths
out of the 100 perforations they describe. The vast majority of their
cases failed of recognition at the time of the injury and lienee de¬
veloped a generalized infection.

IMCBEASE in PE£FO RATIONS, iqiO-23

H A /V\ B U kLG- , 1 34 CASES .

FH-E

1 9 3 S' 33

Fig. 87. — Graph of incidence of perforation in abortion cases from 1910 to 1923
in the city of Hamburg reported by Herbig. Noteworthy are the decrease during the
war years and the pronounced increase in the succeeding five years.

In Herbig ’s report 35 out of 134 died, equivalent to 26 per cent. In
the compilation of Liepmann and Weis, 83 out of 266 with perfora¬
tions died (31 per cent). Koblanck reports 22 deaths in 39 cases
(55 per cent).

These figures justify the conclusion that perforation of the uterus
occurs about once in every two or three hundred evacuations of the
uterus; and that, every second or third perforation ends fa, tally.

The agent most frequently responsible for this injury, it must be
confessed, is the physician. The midwife and lay abortionist are

226

ABORTION

relatively less often responsible, for they are usually content to rup¬
ture the membranes and instil some fluid into the uterus. Of course
such measures have other dangers attendant upon them such as infec¬
tion and embolism, but perforation is less often a result. In Liep-
mannTs latest monograph he reports 21 out of 23 perforations done
by physicians. Herbig in the report on 134 perforations found 99
done by physicians, 27 by abortionists and patients, and 14 uncertain.
Zangemeister 7s percentages are: 72 due to doctors, 17 due to midwives
and the laity, and 11 due to the patient herself. Similarly, we find in
the Peham-Katz monograph that 71 of the 100 perforations resulted
from instrumentation by physicians. In the case of the legalized
abortions in Russia the perforations were all done in the clinic by
physicians.

Analyzing the instruments responsible for the perforation we find
that in those produced by physicians the curette is by far the most
common offender. In Herbig ’s report the following appears : curette,
40 times ; dilators, 28 times ; finger, 5 ; laminaria, once. In perfora¬
tions done by patients, 16 out of 18 were due to the use of syringes,
and where abortionists were responsible the syringe was employed in
all 5 cases. Peham and Katz stress the fact that where the finger is
used for evacuating the uterus perforation is extremely rare and cites
Fromme’s compilation of 322 perforations, 97 per cent of which were
due to instruments and only 3 per cent due to the finger. In Joseph’s
series the 23 perforations made by physicians were due to the sound
once, the curette 8 times, dilators 7 times, and ovum forceps 7 times.
The last named produced the most serious injuries. Schreiner de¬
scribes a case in which a patient used an intra-uterine syringe the
stem of which broke off after penetrating into the cul-de-sac. Liep-
mann and Weis reporting on 153 cases give perforation as due in 31
per cent to the abortion forceps ; in 28 to the curette ; in 18 to dilators ;
in 13 to a catheter; in 9 to the sound; and in 3 per cent to the finger.

In the accident of perforation an important factor seems to be the
conditions under which the evacuation of the uterus is attempted.
With poor illumination in the home or office, with a patient only
partially anesthetized, if at all, and with the physician, often poorly
trained, and under nervous tension in the midst of the bloody pro¬
cedure, it is really a wonder that perforation does not occur more
frequently than it does! Such an evacuation, which involves groping
around blindly in the recesses of the uterine cavity with an instru¬
ment, is in many ways more dangerous and more difficult than a lapa¬
rotomy done under the favorable illumination of the operating room.

PERFORATION

227

Fig. 88. _ Autopsy findings in perforation of the uterus. This patient was curetted in the office of a physician^five days previous

to her death from peritonitis. ( Liepmann : Die Abtreibung, Urban und Schwarzenberg, "Wien, 1927.)

228

ABORTION

The mistake most often made is in proceeding with evacuation be¬
fore the cervix has been thoroughly dilated. In early abortions done
on primigravidae dilation is difficult and false passages may readily
be made. Liepmann in his monograph ‘ ‘ Abtreibung” gives many
excellent pictures showing the manner in which perforation may
occur (Figs. 88 and 89). In 67 out of the 100 cases recorded by Peham

.Fig- 89. — Huge perforation of the uterus produced by ovum forceps with fetus and
placenta extruded into the abdominal cavity. (Liepmann: Die Abtreibuna , Urban
und Schwarzenberg-, Wien, 1927.)

and Katz the cervical canal had not been thoroughly dilated before
evacuation of the uterus was begun. In other cases the dilators were
not properly gauged in relation to the depth of the uterine cavity so
that the instrument was passed through the uterine wall into the
peritoneal cavity. A hypodermic of 1 c.c. of pituitary extract given
just before operation contracts the uterus and lessens risk of per¬
foration.

PERFORATION

229

It lias already been shown how frequently the curette is the offend¬
ing instrument. Where a blunt curette is employed, it may carelessly
be pushed too high into the uterine cavity and make a hole through
the soft relaxed walls of that organ. Dickinson’s curette has notches
like a uterine sound to indicate the depth of penetration of the in¬
strument. More readily is such an injury accomplished with a sharp
curette scraping around the fundus, especially if the pregnancy has
advanced beyond the twelve-week period of gestation.

Most serious of all are the injuries produced by grasping instru¬
ments such as the ordinary dressing forceps and ovum forceps. Too
often the maxim has been forgotten that such instruments are only
to be employed as a means of removing already loosened pieces of
the ovisac lying free in the uterine cavity. Instead of this it happens
not infrequently that such grasping instruments, handled blindly,
catch first portions of the uterine wall and then, as the evacuation
proceeds, enter through such open or weakened spots into the ab¬
dominal cavity where omentum or pieces of the intestine are pulled
down, bruised, crushed or actually torn off under the impression that
they are portions of the ovisac (Fig. 90).

In general the injuries thus made can be divided into :

(1) those situated outside of the peritoneal cavity;

(2) those that perforate the peritoneum; and

(3) those that after peritoneal perforation also damage other or¬
gans lying within the pelvic and abdominal cavities.

In Liepmann’s cases he reports under the first of these groups 26
perforations into the broad ligament and one through the cervical
canal. Under the second group he has no case, but under the third
head he includes 25 cases of intestinal injury, 2 cases of omental
injury, and 2 cases each in which the tube and ovary were crushed. In
the compilation which Liepmann and Weis gathered there were 55
injuries to the small intestines and 25 injuries to the large intestine
out of 266 perforations. In Herbig’s report cited by Heynemann
there were, out of 134 cases, injuries in the following locations:

Parametrium _ 26

Intestine _ 25

(small intestine, 18; sigmoid, 4;
rectum, 2 ; descending colon, 1 )
Mesentery _ 6

Omentum
Ovary

Tube _ 1

Tube and Ovary _ 1

Cervix _ 1

Zangemeister found that in 45 per cent of perforations there were
associated injuries to the intestine, mesentery, omentum, adnexa or
bladder.

to to

230

ABORTION

Conditions. — Among the factors predisposing to perforation are
first, conditions of the uterus altering its position or the shape of the
uterine cavity ; and second, those in which there is no uterine pregnancy.
With a retroverted uterus, an instrument may be inserted in the

Fig-. 90. — Intestinal injury associated with perforation of the uterus. With in¬
sufficient cervical dilatation an ovum forceps was introduced into the uterus ; tissues
were grasped blindly, producing a perforation through which the four months’ fetus
slipped into the abdominal cavity, while the forceps pulled down a loop of the ileum
ripping it from its mesenteric attachment. (Liepmann: Die Abtreibung, Urban unci
unci Schwarzenberg, Wien, 1927.)

wrong direction and thus produce an injury before the condition is
recognized. In the sharp anteflexion of certain primigravidae a false
passage may be formed by the dilator with a perforation into the
cul-de-sac (Fig. 91). Certain cases of arcuate or septate uterus are

PERFORATION

231

also very deceptive inasmuch as the curette first passes into one and
then the other horn and the distance cannot be accurately gauged.
Finally a submucous fibroid may so distort the shape of the uterine
cavity that injury may readily be done with the evacuating instrument.

Cases in which no uterine pregnancy exists are not at all uncom¬
mon. Neugebaner has tabulated a long series of such perforations.
In one set there was no pregnancy at all and in the other it was tubal.
In either event in spite of the fact that the uterine wall has consider¬
able thickness, the operator is so baffled by the fact that he cannot
seem to get out the ovisac that he plunges deeper and more recklessly

Fig. 91. — Diagrammatic sketch showing different methods of perforation with the
curette according to the position of the pregnant uterus. (Dickinson.)

until finally his efforts are rewarded by being able to pull down some¬
thing which may prove to be the omentum or intestine. Naturally
the cases in which an ectopic pregnancy exists, usually go into shock
as a result of these rough procedures with rapid and excessive intra-
peritoneal bleeding. The fatalities in this group, owing to failure to
recognize the true condition, are unusually high.

Where intra-uterine treatment is instituted in cases of unrecognized
ectopic pregnancy, Zeitlin reported uterine perforation in 8 per cent.
Out of 28 uterine perforations reported by Smirnow, two were in pa¬
tients with ectopic pregnancy.

232

ABORTION

Prompt diagnosis of the perforation is of the greatest importance.
Even in the hands of well-trained obstetrical surgeons a perforation
will at times occur, but if the accident is promptly recognized and the
necessary operative measures undertaken, few fatalities result. Natur¬
ally the most significant symptom is that the instrument passes beyond
the estimated depth of the uterine cavity. A second symptom is shock
and evidence of internal bleeding.

Treatment. — The care of perforation varies greatly in accordance
with the character of the injury and whether or not it is done under
clean conditions. In cervical injuries Gardlund advises immediate
repair, incising the cervix up to the point of injury and suturing the
wound edges.

There is considerable variation in the treatment of simple perfora¬
tion. Barsky, following other Russian writers, recommends conser¬
vation of the uterus especially in younger individuals ; and considers
that not even a laparotomy is necessary in some cases. On the other
hand in perforations done outside of the hospital the danger of infec¬
tion necessitates prompt surgical intervention. Rahm (Helsingfors)
performed eight laparotomies for perforation with one death. In
three instances a hysterectomy was done ; in five the perforation only
was repaired. Nordio reported six cases with two fatalities and rec¬
ommends extirpation of the uterus instead of attempting to repair.
Michelson advises that in every case of perforation into the abdominal
cavity a laparotomy should be done. Joseph, on the other hand,
thinks that in uncomplicated perforation conservative observation is
justified before deciding on operation. In 18 out of 23 perforations
operated on promptly, there was no mortality. Weis insists that if
there is any intestinal injury a hysterectomy is preferable owing to
the danger of infection. He cites Schweitzer who found a mortality
of 11 per cent where the uterus was left, compared with only 3 per
cent where the uterus was removed. Injuries to the intestine greatly
increase the mortality, as Zangemeister shows, with figures ranging
from 20 per cent mortality in small intestinal injury to 70 per cent
mortality in cases with damage to the large intestine.

The time that elapses after perforation until treatment is instituted
greatly influences the final outcome. Every patient not already hos¬
pitalized must be sent to a hospital at once. Bardenhewer in Berlin
was able to save all of the 21 cases of perforation sent to his hospital
within three hours of the time of injury. In 8 cases the perforation
occurred at the conclusion of the uterine evacuation. In these pa¬
tients with the uterus empty, conservative treatment with ice-cap,
rest in bed for five days and ergot was employed. Only 3 ran a slight

PERFORATION

233

temperature and all were discharged by the eighth day. In 3 in¬
stances although the uterus was not entirely emptied, the perforation
tract could be located with a sound and curettement completed with
avoidance of this false passage. In the 10 remaining patients a
laparotomy was done because a grasping instrument had been em¬
ployed, or no exact data concerning the nature of the perforation
could be obtained. In 6 suture of the perforation sufficed, combined
once with repair of an intestinal injury. In the other four a high
amputation of the uterus was done. Bardenhewer stresses the differ¬
ence in management between injuries caused by a curette and those
caused bjr an ovum forceps. The former may be treated conserva¬
tively, the latter always require laparotomy.

Illuminating is the accompanying Table VI from Heynemann on
Iferbig’s 134 cases at the Hamburg clinic:

There seems no doubt that all these reports are more favorable than
actual conditions. Fatal operative cases are less apt to be reported
than those in which, in spite of serious injury, the outcome has been
favorable. Peham and Katz, whose series comprised 86 fatal cases out
of 100, found that the cause of death was in 72 instances peritonitis
or general septic infection. In only 10 cases was hemorrhage the
cause. These authors stress the fact that the mortality increases with
each hour that operation is postponed after the perforation has oc-

Table VI

Perforation Treatment and Results in 134 Cases

(Reported by Heynemann, Halban-Seitz, Biologie nnd Pathologie des Weibes, Vol.

7, p. 585.)

(1)

(2)

(4)

TREATMENT

DIED

TOTAL

CASES

RECOVERED

NUMBER

PER

CENT

Total -

134

Expectant - 15

Expectant - 15 13 3 19

Operative, total - 118 85 32 27

Vaginal :

Repair _ 5 5 0 0

Hysterectomy - 119 0

Abdominal :

Tamponade

Suture -

Supravaginal hysterectomy

Complete hysterectomy -

4
6

234

ABORTION

curred. For with each hour of delay the incidence of peritonitis rises.
Kronman advises a laparotomy, even if there is already evidence of
peritonitis, followed by drainage. The mortality, however, must be
extremely high. I recently had occasion to operate upon such a case,
to which I was called thirty-six hours after the perforation when the
patient was in shock. The perforation was in the fundus and there
had been considerable intra-abdominal bleeding. The abdomen was
distended at the time of the laparotomy ; some plastic exudate had
already formed about the intestines but there was no intestinal in¬
jury. In spite of repair of the uterus, drainage and supportive treat¬
ment, the patient died of a peritonitis thirty-six hours later.

If the perforation is into the broad ligaments instead of into the
peritoneal cavity, the result is usually a large hematoma between the
layers of the peritoneum (Fig. 92). Treatment, according to Lesnoi,
may be either conservative with ice-caps and opiates or, if the bleed¬
ing is more extensive, will require laparotomy, opening the broad
ligament, emptying and suturing the wound.

Intestinal injuries vary greatly in their extent, and sometimes ap¬
parently hopeless cases may recover if good surgical judgment is
employed and the patient shows the necessary resistance. Sussmann
reports a case in which a large piece of the recto-sigmoid was torn
off. An artificial anus was made. The patient recovered and several
months later a piece of small intestine was used to reconnect the
descending colon and the rectum and close the artificial anus, with
complete recovery. A similar case was reported by Aubert.

Occasionally the perforation is not in the uterus but in a neighbor¬
ing organ such as the bladder or rectum. In the past year I had oc¬
casion to operate on a patient who developed a recto-vaginal fistula
following an evacuation of the uterus for a three months’ miscarriage.
The history indicated that some grasping instrument had been em¬
ployed to remove placental tissue and that the necrotic posterior
vaginal wall had been pinched off by mistake. When I saw the pa¬
tient, a hole large enough to admit a thumb was found in the recto¬
vaginal septum about 4 inches from the vaginal outlet. The repair
of this fistula was extremely difficult but accomplished at the second
attempt. The subsequent almost complete vaginal stenosis was cor¬
rected by a vaginal plastic, with such success that within one year
the patient again became pregnant and was successfully delivered at
term after bilateral perineal incisions to protect the recto-vaginal
septum.

End Results. — When the patient has recovered from the perfora¬
tion, either with or without operative intervention, there may result

PERFORATION

235

sequelae that materially affect her general health. It is not unusual
to open the abdomen for chronic pelvic infection and find in addition
to the thickened adnexa an old perforation wound in the uterus in
which a bit of omentum is lodged. A careful history will then disclose
some previous instrumental interference. At the point where such
an injury to the uterine wall has occurred healing is imperfect. The
down-growth of the uterine mucosa along the tract leads to condi-

Fig. 92. — Hematoma of the broad ligament, following rupture of the cervix due to
forcible dilatation with a bi-pronged instrument. (Liepmann: Die Abtreibung, Urban
und Schwarzenberg, Wien, 1927.)

tions resembling a poorly healed Cesarean scar. Often there is no
definite history of such a previous perforation, so that if a pregnancy
follows, the patient may go to term and in the process of labor a
rupture of the uterus at this point may occur. Several cases of rup¬
ture of the uterus following perforation have been reported.

Nor are cases unusual in which the instrument used for interrupting
pregnancy has slipped through the perforation wound into the peri¬
toneal cavity. Katz in 1922 collected 54 cases in which this accident

236

ABORTION

occurred. After tlie immediate localized peritonitis has subsided, the
agent, whether it be bougie, catheter, a pencil or some form of needle,
becomes encapsulated. The patient may for months or even years
suffer from this localized infection. At times the foreign body lies
in the pelvic cul-de-sac and can then be readily removed by incision
from below. More serious are those cases where it has become lodged
in the abdominal cavity. Such bodies have occasionally been found
high under the liver. Where the subsequent removal necessitates a
laparotomy, the danger of a generalized infection upon opening such
an abscess cavity is very great.

Even where the perforation is attended by immediate laparotomy
and the patient recovers, there may be serious after-effects. If any
appreciable portion of the small intestine has to be removed, there is
marked disturbance of nutrition, with diarrhea and emaciation, that
may end fatally. In other cases the passage of food through the
alimentary tract may be retarded ; there may be partial obstruction
and other similar complications.

Prevention. — Keeping in mind the relative frequency, the high
mortality and the many attendant complications, the prevention of
perforation needs the most careful consideration. Not that anyone
would maintain that every perforation is preventable, for I have al¬
ready referred to cases occurring in the hands of able men, in well-
organized hospitals. The vast majority, however, are unquestionably
due to faulty technique, and particularly to the fact that the evacua¬
tion of the uterus is so commonly regarded as a minor procedure that
can be done by any practitioner under the most unfavorable situa¬
tions at the office or in the home. According to Peham and Katz the
two most common causes are: (1) insufficient dilatation of the cervix
before beginning the evacuation and (2) the failure to employ the
finger wherever possible as the evacuating agent. As to the latter
there is room for argument, for Heynemann believes that in cases of
previous criminal intervention, the finger is more apt to spread in¬
fection to neighboring structures than is the curette or ovum forceps.
It cannot, however, be denied that 95 to 98 per cent of perforations
are due to instruments and only 2 to 5 per cent to the finger (Fig. 93).
Heynemann also points out that with the use of the finger a general
anesthetic must be employed, adding greatly to operative risk in
these exsanguinated patients. Furthermore he claims that bacteria
are more readily carried into the uterine cavity with the finger than
with the curette. Granting that all these contentions are to an extent
true, I am convinced that in every case where the gestation has ad¬
vanced beyond the tenth week, the uterine walls are so soft and the

PERFORATION

237

amount of tissue to be removed so considerable that the careful use of
the finger as a means of loosening placental tissue or as a guide to
the use of instruments is far safer.

Bumm emphasizes the dangers in the use of the ovum forceps.
These forceps must never be used to loosen tissue from the wall, but
only to grasp and withdraw already loosened bits of the ovisac. He

Fig. 93. — -Multiple perforations of the uterus produced by the hand of the operator. This unusual accident
must be attributed to unwarranted roughness on the part of the physician and unusual friability of the uterine
wail. (Liepmann: Die Abtreibung , Urban und Schwarzenberg, Wien, 1927.)

238

ABORTION

also stresses the importance of an open cervical canal before beginning
the evacuation. Krupsky advises carefully introducing the ovum for¬
ceps to the fundus, then withdrawing it slightly, opening it and sweeping
around before grasping the object within the cavity. Only by such
technique can we avoid grasping a portion of the uterine wall. If it
should have grasped the wall, this will be noticed by a definite tug
on attempting withdrawal.

Kunge underscores the careful measurement of the uterine cavity,
avoiding the introduction of dilators or curette beyond the estimated
distance. He said that a perforation may perhaps be forgiven, but
the introduction of forceps beyond the depth of the uterus to a dis¬
tance of 20 or 30 centimeters and pulling down a piece of intestine is
unforgivable.

Liepmann is convinced that the frequency and high mortality of
perforation are largely due to improper training of the average physi¬
cian in the inherent dangers of instrumental evacuation of the uterus
and a failure to employ to the fullest degree the clinical and hospital
facilities available for such patients.

Summary

To summarize the precautions necessary for the prevention of jier-
foration of the uterus, let us remember:

(1) Give a hypodermic of pituitrin before beginning any evacua¬
tion.

(2) Empty the bladder and again determine the position and exact
size of the uterus by bimanual examination.

(3) Dilate the cervix, when necessary, slowly and without force,
measuring the distance of introducing the dilator each time.

(4) In abortions of less than eight weeks7 gestation, use a curette
or ovum forceps gently, carefully measuring depth of entrance.

(5) Use ovum forceps only to remove already loosened pieces.

(6) In abortions over eight weeks’ gestation, if much material is
retained, dilate to introduce finger and remove the abortion products
under guidance or with the aid of the finger.

(0 Except in emergencies, evacuate a uterus only in a hospital un¬
der proper surgical conditions.

(8) Only a physician with proper obstetrical training is qualified
to evacuate the uterus in cases of abortion.

CHAPTER XV

OTHER COMPLICATIONS OF ABORTION

DESIDE SEPTIC conditions and perforation, various other compli-
' cations occasionally attend or follow abortion. The more note¬
worthy are :

(1) Prolonged retention of fetal parts or placenta.

(2) Fatal hemorrhage.

(3) Gangrene of the extremities.

(4) Abortion in double or septate uterus.

(5) Inversion of the uterus with abortion.

Prolonged Retention of Parts

Not infrequently in the absence of marked infection the uterus is
so inactive that portions of the ovisac are retained for long periods
of time. Neugebauer in a monograph on “Fremdkorper cles Uterus”
has cited many instances of the tolerance of the uterine cavity for
such material. Geisenliofer (1924) relates instances of the retention
for several years of fetal bones when the abortion occurs in the fourth
to the sixth month of pregnancy. The soft parts undergo liquefaction
necrosis but the bones dig their way into the uterine wall and are not
expelled (Fig. 94). The fetal skull may at times remain intact, and
in Volkmairs case was retained for seven months. Fetal bones were
removed by Oldag four and eleven months, respectively, after an
abortion. Both patients had a persistent bloody discharge. A large
portion of the placenta may at times retain a slight attachment to the
uterine wall sufficient to prevent complete necrosis. Such placental
tissue gradually becomes fibrotic and as in Guillemin’s patient may
remain within the uterus as long as eighteen months. Such pieces of
placenta are grayish in color and have the consistency of a myoma,
for which they are sometimes mistaken.

Fatal Hemorrhage

The severity of bleeding has a fairly constant relation to the period
of gestation in which abortion occurs. While severe hemorrhage is of
more frequent occurrence than in full-time deliveries, fatal bleeding
is less common. In a certain number of instances, however, bleeding

239

240

ABORTION

may be so persistent that death ensues. Out of 4,595 abortions in
Bass’1 report from 1917 to 1926 two such fatalities occurred. To the
six cases reported by Heynemann, Federlin could add twelve deaths
from hemorrhage following abortion, including 3 cases of Schneider;
2 each of Bass and Latzko ; one each of Kiefer, Hammersehlag, Hein-
sius, Oing, Mandelbaum, and one of his own. In most of these curet¬
tage was done without previously fortifying the exsanguinated pa¬
tient with a blood transfusion. With the increased facilities for trans¬
fusions in a well-regulated maternity hospital, such deaths should be
almost certainly preventable. Only where patients cannot be trans-

YifC WC1!18 coritaining- fetal bones, removed 11 years after an induced abortion
~ ur and half months’ gestation. (Case of Dr. F. R. Smith, Am. J. Obst. and
Cynec., December, 1933.)

ported to a hospital, or in rural districts, will fatal hemorrhage at
times be unavoidable.

According to Nevermann, the incidence of hemorrhage as a cause
of death after abortion is 2 per cent. In Kief, Magid recorded four
deaths from hemorrhage in 33,000 abortions in eighteen years. These
reports come from hospitals and probably underestimate the total
number of these deaths. The report on maternal mortality in New
York City from 1930-1932 showed twenty-seven deaths from hemor¬
rhage out of 357 abortion deaths, 258 of which occurred at the pa¬
tient s home. Ihis would make an incidence of 7.5 per cent deaths
from hemorrhage.

OTHER COMPLICATIONS OF ABORTION

241

While the flow of blood is in almost every instance outward from
the uterine cavity, it may happen that the uterine end of the tube is
exposed by the loosened decidua and blood may flow through the
tube into the peritoneal cavity. Sampson has shown that such intra-

Fig. 95. — Gangrene of the leg after postabortive thrombosis. The upper drawing
shows early changes ; the lower one shows later pronounced necrosis. (Redrawn from
Halban-Seitz. )

peritoneal oozing of blood may occur at menstruation. In the case
reported by Downing 300 c.c. of blood was in the pelvic cavity at
operation. This patient survived.

242

ABORTION

Gangrene of the Extremities

Unilateral gangrene of the lower extremity is usually due to a septic
thrombus. Symmetrical or bilateral gangrene is usually the result of
an overdose of ergot. Yon Pall reports a fatal ease of rapid gangrene
of the leg associated with septic embolism in the femoral artery fol¬
lowing criminal abortion. He advises amputation of the leg, since
Zweifel found that out of 30 cases without amputation all died,
whereas in 24 cases with amputation 18 were saved. Where such
gangrene is part of a generalized sepsis, however, such radical meas¬
ures are hardly justified (Fig. 95).

Fig-. 96. Bicornuate pregnant uterus, a complicating- factor in the diagnosis and
treatment of abortion. (Kelly: Operative Gynecology .)

Symmetrical gangrene of the lower extremities occasionally follows
upon the use of large amounts of ergot or its derivatives. Heyer
(1927) decided that in his case there must have been a previously
existing tendency to spasm of the blood vessels. Only one c.c. of
gynergen given hypodermically and twelve tablets of this drug given
over four days* time resulted in gangrene of both feet requiring am¬
putation just below the knee to save the patient’s life. Septic em¬
bolus was excluded by the subsequent pathologic examination. The
case of De Senibus (1928) ended fatally even though ergot was
promptly stopped at the first sign of gangrene.

Abortion in Double or Septate Uterus (Fig. 96)

The tolerance of the pregnant uterus to instrumental interference
is at times amazing. Repeatedly we see that in spite of a fairly vigor-

OTHER COMPLICATIONS OF ABORTION

243

ous use of the curette the attachment of the ovisac is missed and the
pregnancy continues to develop. This is particularly likely to occur in
the case of bicornuate uterus with a single cervix, in which the
curette slips into the non-pregnant horn of the uterus. Even an

Fig. 97. — Inversion of the uterus produced by the faulty use of the ovum forceps
in retained abortion. In the left-hand figure the forceps is grasping the soft uterine
wall, indenting it ; in the right-hand figure the inversion has been completed with the
placenta still attached to the uterus.

arcuate uterus with septate cavity will permit continuance of de¬
velopment although the entire decidua is scraped away from the non-
preguant side. In the case of Itzkin two curettements were done at
intervals of four weeks without effect and the pregnancy finally was

244

ABORTION

interrupted at the third month by other means. He believes the non-
irritabiltiy of the double uterus to be due to separate contractility of
the two halves. Esch’s patient was curetted three times and subse¬
quent lipiodol injection of the uterine cavity showed a septate uterus.
Interesting also was the case described by Garfunkel in which both
horns of a double uterus contained a pregnancy. One was removed
by a dilatation and curettement but the other pregnancy continued to
develop until four weeks later when it too was removed in similar
manner. R. Falk reports a similar case : pregnant for the third time,
with heart disease as an indication for therapeutic abortion, dilators
were used and a ten weeks' ovum extracted with ovum forceps, the
cavity curetted, and a gauze drain left in the cavity for twenty-four
hours. No pains or bleeding followed, but two months later a preg¬
nancy of four and one-half months was diagnosed. The diagnosis of
a double uterus with twin pregnancy was made at this time. Pro¬
longed repeated bag dilatation finally opened up the canal on this side
and a fetus corresponding to five months’ gestation was extracted.
Digital palpation revealed a. thick septum separating the two cavities
extending to the cervix.

Inversion of the Uterus with Abortion

If the ovum forceps is improperly used, we may have a resulting
inversion of the uterus as in the case reported by Dunkel. He
suggested, a modification of the forceps to prevent this accident, but
Zangemeister in discussing this case emphasized that the ovum for¬
ceps should be employed only to remove already loosened bits of pla¬
cental tissue, and never to pull such tissue from its attachment. Per¬
forations are apt to result from such a mistake and occasionally an
inversion of the pregnant uterus may take place especially if the
cervix is widely dilated or torn (see Fig. 97).

CHAPTER XVI

MISSED ABORTION

HTHE TERM “ MISSED ABORTION’7 was first employed by Duncan
in 1874 to describe that group of cases in which the ovisac was
retained for some time after the death of the fetus. Long before this
time, however, we find descriptions of cases of missed abortion classi¬
fied as false conceptions {Be conceptu fatuo). Confusion also arose
between these false conceptions and submucous pedunculated fibroids
of the uterus, and in 1686 we find an interesting frontispiece (Fig. 98)
to Lamzweerde’s “De Historia M old rum," in which the doctors are
debating concerning the possibility of a pregnancy in their patient, one
of them stating: “I have faith in her virginity ( Virgini fidem dedi).”

While some objection has been raised by Niirnberger and others to
the use of the expression “ missed abortion, 77 no better name has thus
far been suggested, and I have therefore preferred to retain it. What
a significant part of all spontaneous abortions is to be included under
this head can be seen by the fact that Litzenberg, in his interesting
chapter on abortion written for Curtis' Gynecology and Obstetrics,
has devoted about one-third of his space to this subject. I agree with
Litzenberg in his statement that it is a much neglected subject.

An attempt to define the limits of retention to which missed abor¬
tion may be applied leads to many difficulties. Fraenkel included
only those instances in which the ovum was retained bevond the nor-
mal termination of the pregnancy. Such a definition would limit it
to a relatively small number of molar pregnancies and is not gener¬
ally accepted. On the other hand, Litzenberg placed an arbitrary
limit of two months after the death of the fetus, as the borderline
between abortion and missed abortion. The statement made by
Rhodes, that the fetus is usually aborted a few days after its death, is
certainly not true. Seitz and Streeter both find as a result of their
investigations that an interval of four to six weeks usually elapses
between fetal death and abortion. Streeter’s statement is as follows:

“Among our records are 437 cases of retention of the dead fetus
for which there were reliable histories of the menstrual age. Reten¬
tion was calculated on the basis that the discrepancy between the
menstrual age and the age according to size, represents the approxi¬
mate lapse of time between the death of the fetus and the time of its
expulsion. In this way it was learned that the dead fetus is ordi-

245

246

ABORTION

narily retained about six weeks, the retention being somewhat shorter
in the earlier and somewhat longer in the later weeks. In excep¬
tional cases retention may be greatly prolonged (missed abortion). ”

Lu g-duni Bata vo rum

Apua PETRUM vander Ax . mb Cixxxvi.

Fig. 98. — Frontispiece from Lamzweerde’s “History of Uterine Moles.” In the
foreground the doctors are debating, and one of them is saying, “I have faith in
her virginity.” On the sick-bed lies the patient, who has just expelled a submucous
myoma resembling a molar pregnancy, and declares: “In what manner this fetus
developed I do not know.” (Enlarged from original.)

(Carnegie Inst. Year Book, 1931, Report Dept. Embryology, p. 15.)

I cannot see that we are justified in drawing any hard and fast line,
and believe that we should include all cases of fully retained ovisac

MISSED ABORTION

247

under this head. The clinical symptoms and pathological changes are
more pronounced where the retention has been more prolonged, but
are not essentially different.

Etiology

The causes that underlie prolonged retention of the ovum may be
sought either in the uterus or the ovum itself.

Fig'. 99. — Missed abortion. Hemi-section of uterus containing a four months’ fetus
and placenta, removed because of maternal tuberculosis. Although the lower half
of the uterine cavity is filled with a blood clot, the cervix is still undilated. (Wash¬
ington University Department of Obstetrics.)

According to Von Graefe, the prolonged retention is due primarily
to a decrease in the irritability of the uterus (Pig. 99). As evidence
of this he calls attention to the fact that in such individuals dilatation
of the cervix by instruments, laminaria or gauze pack, usually fails to
bring on uterine contractions* This may however be true in many

248

ABORTION

instances where no missed abortion is present. Fraenkel believes that
prolonged lactation tends to produce such sluggishness of the uterus.
Chronic endometritis and chronic metritis have also been considered
as possible causes. The inclusion of retroversion of the uterus as an
etiological factor seems a bit far-fetched.

Since in many of these cases there occurs a blood-tinged, often
brownish, vaginal discharge, with backache and slight cramping,
pointing to a threatened abortion, a number of these patients are kept
in bed under sedatives for a week or two, and the tendency to reten¬
tion of the ovisac is increased thereby.

A possible explanation seems to me to lie in the very gradual
changes that bring on fetal death in these cases, and the continued
activity that persists in the fetal membranes. In this way the ovum
does not react upon the uterus as a foreign body and hence contrac¬
tions are not aroused. Modification of the endocrine secretions that
occurs in these patients may have a sedative effect upon the uterus.
According to Schaeffer the intrauterine retention of abortion ova
arises from the fact that up to the fourth month of pregnancy the
circulatory system in the fetal membranes is relatively greater than
in the embryo. As a result of this the death of the embryo produces
relatively minor disturbances in the maternal decidual circulation.
The basal portions of the ovisac are nourished and conserved for some
time and the reaction of the uterus is therefore not what it would be
to a foreign body such as a completely separated ovisac.

Equally difficult of explanation are the factors that finally bring on
uterine contractions and expulsion of the ovum after the prolonged
retention. Low grade infections, associated with the slight cervical
dilatation and the bleeding that often occurs, have been given as a
cause. Pressure against the internal ring of the cervix, or against the
paracervical ganglia, as explained by E. Fraenkel, may possibly be a
factor. Again we look to endocrine factors for explanation. The fact
that the endometrium will in cases of prolonged retention become
completely restored and that expulsion of the abortion sac will often
occur simultaneously with the first return of menstruation points to
an ovarian follicle secretion as the cause of returning uterine irrita¬
bility.

Frequency

Until recently, missed abortion was considered sufficiently uncom¬
mon to justify case reports from time to time in medical literature.
Up to 1896, Von Graefe had collected 70 cases, and E. Fraenkel
brought the number to 105 in 1903. After more attention was paid to
a careful comparison of the embryo and its sac with the clinical his-

MISSED ABORTION

249

tory of a patient, it became evident that missed abortion was really a
very common occurrence. Both Williams and DeLee state this in
their text-books ; and Litzenberg stated that he had seen 23 such
cases. In my private practice in the last five years, by far the greater
number of abortions were spontaneous, and in not less than a quarter
of these the sac had been retained for some time after fetal death. In
at least a tenth the retention was long enough to justify classification
under the head of “missed abortion.”

Pathology

In the chapter on pathology of abortion, we have described the
changes occurring in retained placenta. In many ways the changes
that are found in the ovisac of missed abortion resemble these. The
placenta is usually hard, dried, shriveled and tough, and has a yel¬
lowish white color. Infarcts are numerous. Here and there a small,
sub-chorionic hemorrhage can be seen. Naturally the changes are
more pronounced in cases where the ovum has been retained a longer
time.

Histologically, we find in the placental areas, inter-villous spaces
filled with partly hyalinized blood. The chorionic villi show mucous
and hyalin degeneration, and the epithelium covering them is in part
missing (Fig. 100). In some areas, however, the syncytial covering is
absolutely normal, and shows evidence of recent growth. Calcium
deposits occur first in the surrounding layer of blood fibrin, later in¬
volving the tissues within the villi.

In 1901, in connection with a study of mole pregnancy, I stressed
the fact of continued placental vitality after the death of the embryo.
This was criticized at that time by many writers, in spite of the work
of Mall, Grosser and others, upon which it was based. Since then the
evidence of such placental vitality has accumulated, so that it is ac¬
cepted by all embryologists. The fetal epithelium, which is most ac¬
tive in this process, shows numerous fresh syncytial buds. Only the
Langhans layer shows evidence of obliteration. In the connective
tissue of the chorionic villi, we note in some areas absence of blood
vessels. Of special interest are the changes occasionally found in
which these villi become markedly edematous so that even in the gross
examination they can be seen as minute vesicles, not unlike those
found in hydatidiform mole. As seen in Fig. 101, the histologic pic¬
ture is also very suggestive of such a possible malignancy, although
the proliferation of fetal epithelium is much less pronounced in these
cases of missed abortion. I cannot agree with Thelin, who fears the
development of a chorio-epithelioma and advises active treatment in

250

ABORTION

all cases of missed abortion. There is no clinical evidence substanti¬
ating the fear of this complication, even where the abortion was re¬
tained for a long time.

The decidua, which is amply nourished by maternal blood, retains
its vitality for a long time. Here and there we find areas of necrosis
associated with partial detachment of the placenta from the uterine

” >*$>>•' .

• -t ’ ■ ' „»• . v.'.';- ,

‘ Aw *rT. ;->V' Wc-

■\. V .< -V- ■ ;

V iJjV- •• -Vf

- '-mm#1'*'

; 51 mM

■ - a, ■ v

-A yv:y:

•y:- •

Fig-. 100. — Microscopic section of degenerated chorionic villi in missed abortion.
The connective tissue has a glairy appearance and the syncytium is almost entirely
gone.

wall. The blood vessels of this decidual layer are greatly dilated.
Where the retention of the ovisac has extended over a period of
months, we find a tendency of the endometrium to regenerate over a
large area of the uterine cavity (Fig. 102). Stieve and Fuge describe
the histologic picture in a case of missed abortion in which the uterus
was removed. They found the uterine mucosa completely covered by
epithelium, but still rather flattened and thin, with glands running

MISSED ABORTION

251

parallel to the surface. The uterine wall showed evidence of involu¬
tion as after delivery. Rosenstein found degeneration of the uterine

Fig. 101. — Section of hydropic chorionic villi occasionally found in missed abortion
and molar pregnancy. They resemble in some ways the villi found in hydatidiform
mole but show no such proliferation of the trophoblast layers. (Compare with Fig.
114.)

Fig. 102. — Missed abortion with early fetal death. This drawing shows the re¬
generation of almost the entire endometrium with the retained ovum remaining at¬
tached to one point of the uterine wall. Menstruation may return at this stage.

blood vessels and the neighboring wall. It is probable that these de¬
generative changes, together with an inability of the uterus to undergo

252

ABORTION

further involution, are responsible for the tendency to severe bleeding
after the removal of such a retained ovisac.

Coming now to the changes in the amniotic cavity, we find that in
many cases associated with the continued growth of the fetal mem¬
branes after embryonal death, there is a definite increase in the size
of this cavity, and an early hydramnios (Fig. 103). In discussing
hematoma-mole formation, this matter will be given further consid¬
eration. Even though in the early stages of retention, there is at
times such an increase in amniotic fluid, it is universally true that in

Fig-. 103. — Hydramnios ovum in missed abortion, showing- relatively large amniotic
cavity with pathologic embryo attached by a stump-like cord. (Washington Univer¬
sity Department of Obstetrics.)

longer periods of retention, especially in pregnancies of over three
months’ development, the absorption of amniotic fluid is so pronounced
that the embryo is often directly compressed by the surrounding pla¬
centa. Sometimes only a few drops of fluid are present.

Concerning the pathology of the ovum in retained abortion, we
must fall back largely upon the fundamental work done by His and
Mall in the first decade of this century. In Mall’s Human Embryology
(Chapter 9), he gives in great detail the important changes occurring
in these embryos. The greater part of this pathological material was
sent to him, not by physicians who were in search of normal fresh

MISSED ABORTION

253

specimens, but by midwives who sent all types of abortion ova to his
collection at Johns Hopkins. Embryos that were recently dead, or
alive at the time of abortion, were translucent so that blood vessels
could readily be distinguished. Those that were pathological had a
dull gray color and were somewhat amorphous. Mall says:

“ Embryos that die suddenly are usually aborted at once, and if
they are not they macerate and disintegrate, but do not continue to
grow in an irregular fashion as do pathological embryos. The latter
become rounded, grow into nodular or cylindrical forms, but do not
die immediately. Judging by the well-preserved state of the tissues
so frequently encountered, especially the epidermis, I am inclined to
the belief that they lived up to the time of the abortion. However,

Fig-. 104. — The blighted ovum. No. 16 shows an unusual nodular form. In No. 17
we see a kidney-shaped pathologic embryo. No. 18 shows the microscopic cross-
section of a vesicular embryo attached to its chorionic membrane. (Mall and Meyer.
Carnegie Contributions to Embryology, 1921.)

viewed with the naked eye, the embryo is usually opaque, the borders
of the internal organs are quite obscure and no blood vessels are
seen through the skin. Furthermore, the sharp outlines of the bran¬
chial arches, head, hands, and feet are often wanting ; the embryo is
not dead, but has grown in an irregular way, just as do fish, frog and
bird embryos when experimented upon.”

These changes are noted early in retained embryos. Hock, in an
embryo retained ten days in the uterus after fetal death, found re¬
gressive changes in various organs, with round-cell infiltration, but
evidence of continued tissue growth even after death. Autolysis is at
the bottom of these changes, in the opinion of Umbach. This writer
believes that the round cell invasion does not come from either ma-

254

ABORTION

ternal or fetal circulation, but that these cells are really altered organ
cells, since they are not found in either the placenta or the cord. The
structure of the organ is often lost by this autolytic change. The
absence of any circulation in these retained ovisacs, according to
Umbach, is demonstrated by the absence of calcium deposits in them,
even where retention for many months has occurred. In autolysis of
organs the end-products of the changes remain stationary owing to
lack of circulation. Some organs look like lymph glands and stain
poorly.

Mall calls attention to the large number of these cases, 28 per cent
of his series, in which an embryo was completely lacking. In over half
of these with absent embryo, no amnion was found. Mali divides his
pathological ova under four heads :

“Group I. — In the first group are the vesicular forms in which the
main remnant of the embryonic mass is composed of the umbilical
vesicle. In some of them the amnion is formed and in others it is
destroyed entirely.

“ Group II. — In the second group there is neither amnion, embryo,
nor umbilical vesical ; only the chorion remains. This group must
have formed from that variety of Group I in which there is no amnion
present. Vesicular and solid moles may arise from this group.

“Group III. — In this group the embryo was destroyed after the
amnion had been formed; usually it lines the chorion. All stages of
the complete destruction of the embryo are found in this group, from
a necrotic, granular mass to a vesicular ovum lined by the amnion
with but a very short stump of the umbilical cord left.

Group IV. — The embryo is present in this group and is more or
less degenerated. I11 case it is much degenerated it may produce a
nodular embryo of His or an amorphous embryo of Panum.

“Usually after the fifth week it is quite easy to recognize the stage
in which the embryo became pathological. The younger ones corre¬
spond with His Ts abortive, atrophic, or degenerated forms, the older
ones often with his cylindrical forms. I have found it more conveni¬
ent to arrange them in weeks according to the age of the embryo at
the time the pathological process began. The embryos of any given
week may contain any of His’s atrophic forms according to the extent,
degree, and duration of the pathological process. It is noteworthy
that there are so few pathological embryos of the fourth week in my
collection, while relatively there are four times as many in His's col¬
lection. Just the opposite is the case with the vesicular or nodular
forms. It may be that I have had a tendency to class with these

MISSED ABORTION

255

embryos those that he classes with the nodular form. The vesicular
are intermediate between ova with pathological embryos of the fourth
and fifth weeks.”

In the accompanying Table VII will be seen the distribution of 159
pathological ova according to these groups, and also the condition of
the chorion.

Table VII

Distribution of Pathological Ova in Collection of 434 Specimens
Length Crown to Rump, and Condition of Chorion
(From Mall: Human Embryology, 1910, p. 224)

GROUPS

(1)

LENGTH

CROWN

RUMP

(MM.)

(2) (3)

TOTAL

W (5) (6)

CONDITION OF CHORION

OVA

NUMBER

PER

CENT

NORMAL

PATHO¬

LOGICAL

RECORD

Total Cases

—

159

100

113

I. Vesicular Forms _

—

II. Without Amnion or

Embrvo

—

III. Amnion, no Embrvo_

/ «/

—

IV. Embryos, 4th to 10th

Week : _

4th

2.5

5th _

5.5

5.5th

6th

7 th

8th

10'

9th

1.4

10th

42,

0.6

Symptoms and Clinical Course

It is the rule that shortly after fetal death there occurs a slight
bloody discharge and a few cramp-like pains suggesting threatened
abortion. Rest in bed and sedatives will usually cause these symp¬
toms to disappear. Then the patient goes about her usual duties with
an occasional brownish tinge to the vaginal discharge, but oblivious
of the fact that the pregnancy is not advancing. After a lapse of
weeks, or even months, the patient becomes conscious that something
is wrong, owing to the absence of enlargement or the failure to feel
life. If fetal death occurs after the fourth month, the cessation of
fetal movements will be noted. In some instances, she may mistake
the recurring bleeding for irregular menstruation, believing that after

256

ABORTION

all she may not be pregnant. Litzenberg says that these patients have
increasing invalidism, loss of weight, chilliness, a foul taste in the
month and a bearing down weight, “like a stone in the abdomen.”
He even speaks of grave anemia and mental derangement in these
cases of retained abortion. I have not seen any such severe symptoms
from retained abortion, nor can I believe that they are very common.

The symptoms, as described above, are characteristic of the neg¬
lected cases. If the patient consults her physician early in pregnancy
or at the first onset of bloody discharge, and careful re-examinations
are made at intervals of two to four weeks, it should be possible to
recognize most of the cases of retained abortion within one to two
months after fetal death.

Fig‘. 105. — Hyclramnios ovisac, 9 cm. in diameter, with 8 mm. embryo. For the history

of this case see accompanying- text. E. Embryo.

A typical illustration of a case of missed abortion is quoted from
my former monograph (p. 154) :

“M. W., twenty-three years of age, had been married five years.
No previous pregnancy. For several years she had had leucorrhea,
backache and dragging pains in the pelvis. Menses regular, three or
four days in duration, painless. Last menstruation in the middle of
September. In October she had typical morning sickness. No symp¬
toms on the part of the breasts. When she came to me on February
11th, she said she had had some bleeding and abdominal pains for the
past week. In the past two days bleeding had been more severe, and
accompanied by clots. Examination showed a uterus somewhat soft¬
ened, corresponding in size, however, only to about a two months’
pregnancy. She was ordered to rest in bed and was given sedatives,
but the following day, five months after the last menses, the intact

MISSED ABORTION

257

ovisac was expelled. The measurements taken before preservation
showed the greatest diameter of the ovum to be 90 mm., the length
of the embryo 8 mm. (Fig. 105). The placental site had not yet been
established, villi being found in all portions of the o\am. The decidua
was lacking in the area near the point of insertion of the umbilical
cord. The embryo was Avell preserved, but deformed. It dated from
the end of the first month. The ovum corresponded in size to two
and one half months. The pregnancy continued for five months.”

The course of missed abortion varies in its duration from one or
two months to one or two years. The cases mentioned in previous
chapters, in which only fetal parts were retained in the uterus are
not to be included under this head. As a rule, if the retained ovisac
has not been expelled spontaneously within a few months, the patient
will insist that something be done to evacuate the uterus, and very
often the wishes of the patient will be re-enforced by the recurrent,
sometimes hemorrhagic, uterine bleeding.

Diagnosis

The difficulties of accurate diagnosis of missed abortion are very
great. In women with moderately thick abdominal walls, it is often
impossible to determine with any accuracy slight changes in size and
consistency in the uterus. If we have not examined the patient be¬
fore the abortion has begun, w e may even find it impossible to decide
the question of a pregnancy. The differentiation between a submu¬
cous myoma and a retained abortion is not an easy matter. In the
history of the case we may also encounter difficulties. Mianna re¬
ports a case of six months7 amenorrhea, in a women forty years old
diagnosed as beginning menopause. At the seventh month a bloody
discharge suggested further examination, and an ovisac weighing 30
grams was extracted with ovum forceps. There was no visible embryo
in the amniotic cavity when the specimen was opened. Mention has
already been made of the use of the pregnancy and female sex hor¬
mone tests in determining the question of fetal death. Wilson and
Corner report two cases of missed abortion in which the Friedman
pregnancy test was of diagnostic value :

” (1) — Four months pregnant (test positive); three months later
no change in size of uterus (test negative) ; removal of mummified
fetus and infarcted placenta by vaginal hysterotomy.

“(2) — Three and a half months pregnant (test positive); 3 weeks
later, bleeding (test negative) ; two months later, no growth (test
negative) ; uterus emptied and dead ovum and infarcted placenta
found.”

258

ABORTION

In pregnancies near term, these writers found that in spite of a dead
fetus the test was positive.

Complications

In spite of the prolonged intra-uterine retention, we do not ordi¬
narily find any complicating factors in the way of infection of the
adnexa or parametrium. Of unusual interest are the cases in which
in spite of the retention of the abortion ovum, a new pregnancy has
occurred. While extremely rare, they are of such interest in the
whole problem of abortion that some of the recent reports are worth
citing. In the case reported by Jorgen Lovset, a thirty-year-old
patient had five previous children. Her last menstruation was Feb¬
ruary 5, 1931; on March 31, the uterus was the size of a two months ’
pregnancy; on June 16 there was a hemorrhage with expulsion of a
five weeks5 fetus in an unruptured ovisac. In spite of this, examina¬
tion showed that the uterus still reached to the umbilicus. Shortly
thereafter, a placenta corresponding to a four months’ pregnancy was
expelled with empty ovisac. This placenta was very hard, and showed
no evidence of a cord insertion or fetus; it had numerous infarcts.
On the other hand, the fetus in the intact ovisac was certainly re¬
cently dead, and only 1.5 or 2 cm. in length. Lovset explains these
findings as follows :

The first fetus must have died and been completely absorbed, while
the placenta continued to grow. About a month or two after the
death of the first fetus, the patient again conceived, and after the
lapse of five weeks, the new pregnancy aborted and the older placenta
was also expelled.

Even more interesting is the case described by N. K. Forster. His
patient was a Il-para, twenty-eight years of age. Her last menstrua¬
tion was April 16, 1927. By August 30, 1927, the fundus of the uterus
was near the umbilicus. A blow upon the abdomen in September was
followed by slight uterine bleeding. Fetal movements were not felt
at the expected time in September, and in October the uterus was
definitely smaller. In January, 1928, three months later, however,
the uterus was again larger and in March the patient stated that she
had felt life for two weeks. The expected date for confinement was
figured, therefore, for June 22, and labor was induced at this time.
In spite of rupture of the membranes, progress was so slow that in
view of some evident abnormality, a Cesarean section was done. A
child of 6 pounds 14 ounces was delivered with placenta. Inspection
of the uterus showed a small, greenish sac still present. This sac

MISSED ABORTION

259

contained a dead, partly macerated fetus of about five months’ gesta¬
tion, flattened in shape, attached to a flat placenta with many hard,
obliterated cotyledons.

Treatment

Whether expectant or active treatment will be employed in these
cases of retained abortion depends somewhat upon the length of re¬
tention, and the mental reaction of the patient to the fact that she
is carrying a dead ovum. Ergot, quinine and pituitrin can, of course,
be given, but usually have very little effect because of the sluggish¬
ness of uterine contractions. Even the introduction of a gauze pack
into the lower uterine segment and cervical canal will at times fail
to bring about the expulsion of the ovum. Koek advises a waiting
policy in missed abortion, since in his experience we can count on
spontaneous expulsion within three months’ time. If the pregnancy
is not over two months’ duration at the time of fetal death, the slug¬
gishness of the uterus is more pronounced, and the retention of the
ovum is more prolonged. Under such circumstances, it may be neces¬
sary to do an anterior vaginal hysterotomy, introduce a finger into
the cavity to loosen the sac, and remove it with the sponge forceps
or ovum forceps. Since there is often considerable atony of the
uterine muscle with moderately free bleeding, it may become neces¬
sary to control this with a pack before closing the hysterotomy incision.

CHAPTER XVII

MCI jAR PREGNA NC Y

|\ CERTAIN TYPES of missed abortion, the pathological changes

of the ovum are so distinctive as to deserve separate consideration.
Since the ovisac in these cases is ordinarily expelled as a fleshy mass,
the name of “mole” has been applied to it for many centuries. Bor¬
land defines “mole” as a fleshy mass or tumor formed in the uterus
by the degeneration or abortive development of an ovum. In the
literature of the seventeenth and eighteenth centuries, as seen in the
cut from Lamzweerde’s book (Fig. 98), there is much confusion be¬
tween these molar pregnancies and uterine fibroids, especially the
pedunculated submucous type extruding into the vagina. The ab¬
sence of an embryo in many moles rendered the differentiation doubly
difficult. Not until microscopic examinations began to be made
routinely was it clear that we were dealing with a product of gestation.

There are three types of molar pregnancy :

(1) Carneous or Blood Mole

(2) Hematoma Mole

(3) Hydatidiform Mole

Carneous or Blood Mole (Fig. 106). — It occasionally happens that
even though the entire fetal sac has been detached from its decidual
bed, it is not at once expelled from the uterus, but is surrounded by a
layer of blood which coagulates, forming a bloody, fibrinous mass.
By repeated slight oozing of blood, this mass may increase in size until
the coagulated blood is many times larger than the original fetal sac.
Since this process takes place only in cases of missed abortion, where
the embryo has succumbed in the first few weeks of pregnancy, it is
not surprising that as a rule we do not find any embryo within the
amniotic cavity, or at the most a vesicular or club-like form. In gross
appearance such a blood mole has the isosceles triangular shape of
the uterine cavity in which it has been lying for some time before
its expulsion. With the exception of a few gray fibrinous striations,
the color ordinarily will be a wine red with a tinge of brown in the
areas of older bleeding. On cutting open the blood mole, we find in
the center a small spherical cavity lined by amnio-chorion and con¬
taining a few drops of amniotic fluid (Fig. 107). Chorionic villi are

260

MOLAR PREGNANCY

261

scanty and barely distinguishable. The clinical history of such a
blood mole presents no distinguishing points from that of an ordinary
missed abortion, except that it is limited to very early abortions.

Fig. 106. — Carneous mole in situ in the uterus. ( Jaschke-Pankow : Geburtshilfe,

Springer, Berlin, 1923.)

There is considerable resemblance between these blood moles and the
blood clots containing a small amniotic sac frequently encountered in

tubal abortions.

262

ABORTION

Hematoma Mole

One of the most interesting and curious pathological products of
abortion is that described in 1892 by Carl Breus as the “tuberous sub¬
chorial hematoma of the decidua.” Although often referred to as
Breus moles, we find that Pernice in 1852 already showed excellent
illustrations of this condition. The clinical records of the five cases
reported by Breus showed that they all gave a history of products
of abortion retained for an unusually long period of time, and that

Fig-. 107.— -Carneous mole showing small empty amniotic cavity and partly fibrinous
blood capsule. (Washington University Department of Obstetrics.)

the pregnancy itself had never advanced beyond the seventh week
of life, while the ovisac was not expelled until seven to twelve months
later.

I had occasion to make a careful study of eight cases of Breus mole
in the collection of Professor Wertheim in Vienna in 1902, the findings
of which have been for the most part confirmed by subsequent in¬
vestigators. Depending somewhat upon the localization of the cho¬
rionic villi, we find two types of hematoma mole; one, in which the
blood sacs assume a polypoid form projecting from all portions of
the fetal membranes into the amniotic cavity (Fig. 108) ; the other,
in which the hematomata are broad based, crowded together in one
portion of the sac in a hemispherical shape with the remainder of the
membranes normal in contour (Fig. 109). Between the hematomata.

MOLAR PREGNANCY

263

folds of chorio-amnion can be seen crowded together by the surround¬
ing sacs. The blood in these sacs has a dark red color, and is for the
most part clotted. At their base we find strands of fibrin, grayish
brown in color. The decidual covering of the sac has the firm con¬
sistency and brownish color seen in all retained abortions.

Although the sac itself is the size of an orange or even larger, the
amniotic cavity will be found to be almost entirely obliterated and
containing about a half teaspoonful of a fluid having a brownish
sediment. This sediment consists of old blood. Most peculiar are
the pathological changes in the embryo. The term “cylinder embryo ”

Fig:. 108. — Hematoma mole with polypoid hematomata. (H. R. Schmidt in Hal-
ban-Seitz Handbuch, Urban and Schwarzenberg, 1927.)

A. Amniotic folds. B. Polypoid hematoma. G. Edematous umbilical cord. D.
Embryo.

has been applied to this form, because instead of the normal crescent
curve, we find that the head, body and extremities are barely dis¬
tinguishable in the amorphous cylindrical mass.

The size of these embryos is fairly constant, ranging between 8 and
15 mm. in body length. In a few cases, embryos as long as 20 mm.
have been found, but in the larger embryos described by Neumann
there is considerable doubt as to the correctness of the diagnosis.
This definitely establishes the hematoma mole as a retained abortion
dating from between the fourth to the seventh week of gestation.
The microscopic findings in these moles show that the fetal membranes

264

ABORTION

still maintain considerable evidence of vitality. This is particularly
true of the syncytium which shows numerous well-staining buds in¬
dicative of recent cell division. In the amnion epithelium, we also find
the single layer of cells for the most part intact; and in one of the
moles I studied, there was an inclusion growth of epithelium around
small blood masses lying in the amniotic cavity.

Of considerable importance is the fact that the decidua is for the
most part necrotic or in a state of necrobiosis. Its blood vessels are
thrombosed, and there is no evidence pointing toward its active par¬
ticipation in the pathologic process. It is for this reason that Breus’s

Fig-.

author's

1903.)

1l9;iTHeTatoma mole with broad-based hematomata.
series of cases at Bettina Pavilion (Vienna). (Taussi

Specimen from the
g- : Arch. f. Gynak,

original theory and name has been generally abandoned. Whether
the fetal circulation has also ceased to function is a matter of dispute.
Bill found a lack of blood vessels in the chorionic villi of the case
studied by him from Chrobak’s clinic. As shown in the illustrations
of one of my cases (Fig. 110), such absence of fetal vessels is not
necessary for its development. The accumulations of blood are defi¬
nitely in the intervillous spaces, and the fetal membranes over this
aiea are thinned out and the chorion lacking in villous projections.

The histologic description of pathologic embryos given in the chapter
on missed abortion applies equally to those of the hematoma mole.

MOLAR PREGNANCY

265

The head portion shows the most marked degenerative changes. The
various organs of the embryo can be recognized with difficulty owing
to the cellular changes already described (Fig. 11.1).

The clinical history of these molar pregnancies is similar to that
of other missed abortions except that the tendency to bleeding and

Fig'. 110. — Section ol‘ chorion from same case (Fig. 109) showing blood in fetal
vessels. Syn = syncytium ; B = blood ; G- = blood-vessels ; OB = oedematous con¬
nective tissue.

Fig. 111. — Section through cylindrical embryo (Fig. 109), showing partial disinte¬
gration. Ch.D., dorsal cord ; A, aorta ; G.D., ovary ; W.G., Wolffian duct ; D., in¬
testine ; W.K., Wolffian body ; M., spinal cord.

uterine pains is less pronounced, the interruption of the pregnancy
occurs earlier, and the duration of the retention is longer. In several
instances, the mole has been retained for eleven to twelve months
without any appreciable effect upon the health or well-being of the
patient. Practically without exception these pregnancies occurred in

266

ABORTION

women who had previously borne children or had abortions. The age
of the patient usually ranged from twenty-five to thirty years, and in
at least one case there was a repetition of the molar pregnancy. In
Schweitzer's case, the twenty-six-year-old patient expelled the typical
mole 357 days after the last regular menstruation, and 295 days after
the last irregular bloody discharge.

The diagnosis of hematoma mole is extremely difficult because of
the absence of symptoms, the relatively small size of the uterus, the
firmness of consistency of that organ, and the prolonged amenorrhea.
If the case has been observed early in pregnancy, and a positive
Aschheim-Zondek test changed to negative, as in the case reported
by Hammerschlag, we naturally think of missed abortion. Neverthe¬
less in his case previous irregularities and the irregular consistency
of the uterus pointed to the presence of a myoma of the uterus ; hence
a hysterectomy was done, and only upon opening the uterus was it
found to contain a typical Breus mole with many polypoid blood sacs.
Nurnberger enumerates three characteristics for this mole:

(1) There are circumscribed, sub-chorial collections of blood, form¬
ing knob-like projections into the cavity of the ovisac.

(2) There is a disproportion between the size of the embryo and the
size of the ovisac.

(3) There is a striking disproportion between the size of the embryo
and the duration of the pregnancy.

Concerning the origin of these peculiar mole pregnancies, the dis¬
cussion waged fiercely for a decade in German literature. As one who
took an active part in this forensic struggle, I may be pardoned for
restating my own theory at this point. It is as follows (p. 157 of
my 1910 monograph on abortion) :

“'After the death of the fetus in the first or second month of gesta¬
tion, the fetal membranes and the amniotic fluid increase in volume.
Thus there arises a secondary hydramnios-ovum [Fig. 112]. This
growth continues up to a certain point. The ovum is retained. The
amniotic fluid is then gradually absorbed and the ovum as a whole
shrinks somewhat in size. By the negative pressure thus produced,
folds, or invaginations, of the membranes arise which become filled
with the blood circulating in the intervillous spaces. By continued
absorption of the fluid, together with a certain degree of stretching
of the membranes by the blood clots, we have the formation of the
hematomata. In this process the insertions of the villous stems act
as fixed points. If the stems are close together a hemispherical or
broad-based hematoma results; if far apart, a tuberous or polypoid
hematoma."

MOLAR PREGNANCY

267

The point of greatest interest at issue is whether the fetal mem¬
branes continue to grow after fetal death. This was the assumption
of Breus, Gottschalk and others, but has not been confirmed by sub¬
sequent studies, and was opposed to my views at that time. Although
several critics, and more recently H. R. Schmidt, in the “Halban-Seitz
Handbuch” stated that I believed in such a growth of the membranes,
the words I actually used were, “increase in volume.’7 I explained
this as essentially due to an accumulation of fluid in the amniotic
cavity after fetal death, owing to the still vital secreting of the amnion
epithelium. This secondary hydramnios following fetal death, cor¬
responds to the accumulation of amniotic fluid commonly found in the
last months of pregnancy where a fetal deformity interferes with the
swallowing of amniotic fluid. It certainly does not seem far fetched
to assume that fetal membranes that show such vitality should for a
long time be able to produce additional amniotic fluid, which through

Fig-. 112. — Diagrams showing the development of a hematoma mole. A. Normal
relation of a four weeks' embryo to its ovisac. B. Relation of such an embryo to its
ovisac in early hydramnios. C. Multiple polypoid hematomata, arising in such a
hydramnios ovum to form a hematoma mole.

the death of the fetus is no longer needed for fetal metabolism, and
hence is not absorbed as is normally the case. In the past thirty
years, while numerous cases of early hydramnios ova with pathologic
dead embryos have been described, I find no record anywhere of an
early hydramnios ovum with living or recently dead embryo. For this
reason, I cannot accept Davidsohn’s theory of a primary hydramnios
predisposing to the development of these peculiar moles.

The treatment of hematoma mole is essentially that of missed abor¬
tion. As a rule there is no necessity for active interference.

Hydatidiform Mole

In hydatidiform mole we pass from the realm of pregnancy and
its pathological results into that of neoplasms. To go more deeply
into the description, clinical history and pathology of these peculiar

268

ABORTION

moles, would lead to a discussion of cliorio-epithelioma ; and this in
turn would lead us too far astray for the purposes of our monograph.
Since, however, the borderline between physiology and pathology is
in this case as in many others so ill-defined, a few comments are in
order. It has been repeatedly noted, as illustrated in Fig. 101, that
in certain cases of missed abortion we may find small areas of the
chorion where the villi have assumed a vesicular form. Such areas
are to all purposes miniature reproductions of the picture found in
hydatidiform mole. Even more frequently and pronouncedly do we
find these peculiar, grape-like changes in cases of hematoma mole. In
at least three cases, the first of which was described in my study from
Wertheim’s clinic, the involvement by the hydatidiform process was
as extensive as was the formation of the hematomata.

Microscopically these vesiculated villi as a rule showed but little
of the epithelial proliferation commonly associated with hydatidiform
mole. Yet we pass from step to step, from the most benign to the
most malignant changes in this strange metamorphosis of the fetal
membranes. It seems not improbable that when the true theory of
the development of these tumors shall have been explained, it will be
found to be closely associated with the pathologic processes present
in missed abortion.

The frequency of hydatidiform mole is approximately four or five
in every thousand pregnancies, according to Onslow Gordon of Bel¬
levue Hospital. It produces uterine bleeding relatively early and
therefore the diagnosis is often made of threatened abortion without
any suspicion of the peculiar hydatidiform changes. If however there
is an enlargement of the uterus out of proportion to the stage of the
pregnancy, if the bleeding is profuse and not accompanied by the
usual colicky pains, and above all if there is a passage of the char¬
acteristic small, grape-like vesicles, the diagnosis of hydatidiform mole
can be made with certainty (Fig. 113). In recent years the develop¬
ment of the Aschheim-Zondek test has thrown an interesting light
upon the etiology and diagnosis of this condition. This routine preg¬
nancy test is so strongly positive that from quantitive determinations
the diagnosis can be made with reasonable certainty. The reasons
for this must depend upon the underlying endocrine pathology, and
this accounts for the frequent association of the more malignant cases
of hydatidiform mole with corpus luteum cysts of the ovary.

In practically all cases of hydatidiform mole, the embryo has died
and has either been completely liquified or is vaguely recognizable as
a cylinder or nodule, similar to the pathological embryos found in
missed abortion. As an exception to the rule, there has been found

MOLAR PREGNANCY

269

in one or two cases a normal, living fetus, bnt only where the portion
of the placenta involved in the hydatidiform change was at a distance
from the umbilical insertion.

Of the histologic changes found in hydatidiform mole, we need men¬
tion only two :

(1) Marked edema of the chorionic villi with absence of fetal blood
vessels.

Fig. 113. — Hydatidiform mole in process of expulsion from the uterus. (Bumni. )
A. Uterine body. B. Internal os. C. Cervix. D. Amniotic cavity. E. Blood coagu-
lum. F. Fibrinous capsule. G. Grapelike swollen villi of chorion.

(2) Exuberant proliferation of the syncytium and Langhans cells
showing a tendency to invade the maternal tissues and superficial
blood vessels (Fig. 114).

The prognosis and treatment of hydatidiform moles vary greatly
in the individual case and in the experience of various gynecologists.
At one time Schauta recommended that in every case where such a
mole had been expelled, wre should proceed to remove the uterus as
soon as possible in order to prevent the development of that most
fatal type of malignancy, chorio-epithelioma. The development of

270

ABORTION

the pregnancy tests has placed in our hands a yardstick for measur¬
ing the malignancy of these cases that is of the greatest value. While
we must be guided by our clinical experience, as well as by laboratory
tests, we have learned to value the latter very highly in setting the
indications for treatment in hydatidiform mole. If the pregnancy
test remains positive after the expulsion of the mole for a period of
several months, we are justified in the assumption that actively pro-

Fig-. 114. — Microscopic section of hydatidiform mole, showing swollen connective
tissue of the chorionic villi and marked proliferation of the trophoblast.

liferating fetal epithelium has been retained, and hence that a curet-
tement, or immediate hysterectomy, is justified. By the routine use
of this pregnancy test after cases of hydatidiform mole, we can make
possible the earlier recognition of chorio-epithelioma. Since some
cases of chorio-epithelioma develop after abortion, more particularly
after missed abortion, it would seem wise to do an Aschheim-Zondek
test after a lapse of one or two months, especially in those cases where
there is a slight vesicular change in the membranes.

molar pregnancy

271

In the immediate treatment of these cases of hydatidiform mole, a
profuse hemorrhage, the absence of cervical dilatation, and the not
infrequent invasion of the uterine wall by the mole itself, make its
removal a matter of considerable difficulty. This can best be accom¬
plished by operating under local anesthesia with the addition of an
intra-uterine hypodermic of infundin to control the bleeding. The
uterine cavity can be emptied by the combined use of the finger, the
sponge forceps, and the blunt curette. A preliminary blood transfu¬
sion will often be advisable.

CHAPTER XVIII
SEQUELAE OF ABORTION

HUE IMMEDIATE and serious complications attending spontane¬
ous and induced abortion are discussed in earlier chapters. There
are, however, more remote consequences that also have a harmful
effect upon the mother’s health. As is to be expected, these sequelae
are more common after the infected, induced abortion than after
spontaneous interruptions that run a normal course.

Ter-Gabrielian made an interesting analysis of 1,120 women in
Russia who had had abortions. Of this number, 844 had legalized
induced abortions, 197 had illegal abortions, and 79 had spontaneous
abortions. Of the total number, 15 per cent were primiparae and 85
per cent multiparae. The primiparae were more frequent in the il¬
legal induced group. The percentages of early and late complications
in the three groups were as follows:

COMPLICATIONS

SPONTANEOUS

LEGAL

INDUCED

ILLEGAL

None

Immediate

Early

Late

Prom this, it is evident that late complications occur most frequently
in the legally induced group, and early complications in the illegally
induced. Furthermore, spontaneous abortions have complications in
one-quarter of the cases, as compared with more than half in the
induced. Early complications include hemorrhage, anemia and in¬
fection. Under late complications we have conditions such as men¬
strual disturbances, sterility, tendency to repeated abortions, and
various neurasthenias.

These harmful effects are not infrequently due to improper treat¬
ment by the physician. Under this head must be mentioned, in the
fiist place, too vigorous a curettement. Zomakion discusses 24 cases
out of 81 curetted abortions, in which he noted the following sequelae :

(1) Habitual abortion.

(2) Irregular menstruation.

(3) Relative and absolute sterility.

(4) Oligomenorrhea with marked menstrual molimina.

SEQUELAE OF ABORTION

273

These complications are due, in part, to the removal of excessive
amounts of uterine mucosa including' at times bits of muscularis; in
part, to injuries of the cervical canal produced by brusque methods
of dilatation. Too vigorous curettement is particularly apt to produce
bad results in primigravidae.

The most frequent sequelae are those found in the pelvic organs.
P. P. Muller cites a case of atresia of the cervix so pronounced as to
lead to a hematometra. After dilating the stricture, the blood escaped
from the uterine cavity, and the patient was relieved. Serious cau¬
terizing effects upon the uterine wall were noted by Welscli in con¬
sequence of the injection of Leunbach’s paste to induce abortion. A
hysterectomy was done nine weeks after this paste had been injected,
and Welsch found at that time extensive necrosis and destruction of
the uterine mucosa with some deeper penetration into the muscular
coat. The reason for this action is that soap is an important con¬
stituent of all such commercial pastes or salves. Within the uterus,
soap disintegrates into fatty acids and caustic soda, and the latter
produces a deeply cauterizing effect.

Anufrief points out that postoperative supervision should be con¬
tinued for at least three weeks after abortion. Incomplete regenera¬
tion of the endometrium and the presence of necrotic placental ma¬
terial open the road to infection; sterility and chronic pelvic infection
frequently result. Hence, a longer stay in the hospital after curette¬
ment is desirable.

Salpingitis is a frequent accompaniment of infected abortion. The
severe forms of tubal abscess are rare, but the milder lesions asso¬
ciated with adhesions are quite common. In Russia, since the days
of legalized abortion, special attention has been paid to cervical in¬
fections. Operative intervention has been delayed whenever these
were present, because of the frequency with which a tubal or general
infection results from such procedures. Gross reports that in 200
infected abortions at Leipzig, 21 per cent were followed by infection
of the tubes and ovaries. Only one-third of these infections were due
to gonorrhea, the remainder to the ordinary septic organisms.

Mild inflammatory lesions in the tubes do not completely occlude
the lumen but, through agglutination of folds, form pockets in which
the impregnated ovum may become lodged and so predispose to ectopic
pregnancy. We find, therefore, a marked increase in the number of
such tubal gestations following induced abortion, which in Russia
has caused the Government to increase its efforts to restrict even
legalized abortion.

274

ABORTION

Sterility naturally follows in a large number of cases, due to the
pelvic and tubal adhesions of infected abortions. I. C. Rubin, com¬
paring 219 induced abortions with 239 spontaneous ones, found that
the former were far more frequently followed by sterility. With the
increasing number of abortions, the chances for sterility are also in¬
creased. Wojtulewicz found 9 per cent sterility after one abortion,
compared with 18 per cent after more than one. A different opinion
on this subject is expressed by Vogel, who found that the number of
births per years married was the same, whether the women had had
children only, or had had both children and abortions. The majority
evidence, however, points to increase of sterility, the cause of which
may be due to uterine atrophy, cystic ovaries and endocrine disturb¬
ances, as well as to a chronic salpingitis, as pointed out by Serdukoff.

Interesting observations have been made in Professor Braude’s
clinic in Moscow on cholesterin metabolism in connection with artificial
abortion. Kogan, Lewenson, and Libin made four cholesterin deter¬
minations in. each of sixty cases of artificial abortion, two before
operation, one four days later, and the fourth fourteen days later.
The highest cholesterin figures were obtained in the group of primip-
arae, and in the multiparae with moderate toxemia. In cases of
amenorrhea, just as high an amount of cholesterin retention in the
blood was noted as in toxic types of pregnancy. These investi¬
gators showed a definite relationship between abnormal ovarian func¬
tion and cholesterin retention in the blood. The sudden drop in
cholesterin content on the fourth and fourteenth days after operation
points in their opinion to marked disturbance of metabolism following
artificial abortion.

Other blood changes have been investigated by Russian observers.
Golubein studied the blood in thirty healthy, pregnant women, in
whom abortion was induced; specimens being taken before opera¬
tion, several hours after operation, on the fourth postoperative day,
and on the eighth to the twenty-first postoperative day. The hemo¬
globin was usually unchanged or slightly increased, the number of
red cells unchanged, and the white cells temporarily raised to 10,000
in the first few hours. Libin, who collaborated in this work, found
that in 77 per cent the precipitation time was increased for four days
after operation before returning to normal. In 14 per cent, the pre¬
cipitation time remained short even in the absence of fever, although
these cases all showed bloody discharge and painful adnexa. The
coagulation time was unaffected by induced abortion.

Abnormal menstrual flow was observed in 28 out of 63 women who
had aborted, according to the studies of Nichinson. Two-thirds of

SEQUELAE OF ABORTION

275

these had a prolonged flow ; one-third a shortened flow. Nichinson
attributes these changes to alteration of ovarian function by abor¬
tion. In a few instances the pathologic changes in the genital tract
are not sufficient to prevent conception, but interfere with the proper
development of the ovum and so tend to habitual abortion.

Complications in subsequent childbirth are among the most serious
after-results of abortion, more particularly infected induced abortion.
Lankowitz comparing the labors of 1,722 primiparae without previous
abortions with the labors of 661 primiparae who had had one or more
artificial abortions, finds that the latter are more prolonged and dif¬
ficult, with a higher fetal mortality. A similar comparison made by
Klein in Germany showed that adherent placenta, delayed expulsion of
the placenta, inertia of the uterus, faulty presentation of the child, pla¬
centa praevia and postpartum hemorrhage were from two to nine times
more frequent in women with previous abortions. Further evidence is
presented by Bronnikowa, who compared 717 primiparae without abor¬
tion to 653 primiparae with one or more previous abortions, and found
that labor was on the average seven hours longer, forceps more fre¬
quently applied and adherent placenta a common sequela. Placental
abnormalities are particularly to be dreaded. Azleckij found adherent
placenta in 6 per cent of 1,337 post-abortion confinements, whereas
the average incidence for all 4,278 pregnancies studied was only 2.5
per cent. Out of the total of 110 manual removals of the placenta
done in this series, 83 were in the post-abortive group, while in the
group that had had no abortions, manual removal was required only
27 times, or less than one per cent. TVTe should mention also the report
of Ritala, from Finland, who studied 856 cases, 406 of which had had
abortions at one to three months ’ gestation. A prolongation of labor
was noted in those with previous abortions. This occurred primarily
in the first stage (20 to 25 hours) and was due, in Ritala ’s opinion, to
rigidity of the cervix produced by post-abortal infection.

One voice alone is raised to contradict these statements. Atzerodt,
comparing 3,964 births without previous abortion to 184 births with
previous abortion, finds the latter if anything more free from com¬
plications. His post-abortive cases are, however, too few to controvert
the evidence of other men. Atzerodt believes bad technique is more
responsible for such complications than the abortion itself. This
opinion is also expressed in Japanese literature by Ogawa, who does
not, however, give exact figures as evidence.

That there is a mental as well as a physical strain attendant upon
the illegal induction of an abortion is to be expected. The fear of
prosecution by the law, the moral conflicts involved, and the anxiety
as to the outcome of the operation, all result in a mental strain, which

276

ABORTION

in a pregnant woman with lowered nervous resistance may end in a
true psychosis. Not only is the immediate psychic state to be dreaded,
but in the practice of the neurologist and psychiatrist many a mental
case, after careful analysis, will be shown to date back to the terrify¬
ing experience of an induced abortion. To take a few examples from
recent literature, Ivankeleit relates the story of a woman who was
suddenly seized with vomiting and a choking sensation after seeing
c 1 d b ^ug in bed, apparently dead. Hypnotic suggestion gave
temporary relief, but cure was effected only after the mother con¬
fessed that ever since she had produced an abortion two months pre¬
viously she had been in constant fear of prosecution and punishment.

An antipathy to her children amounting to a psychosis was the re¬
sult of an illegal abortion in the patient treated by Timm, and was
^ * i « psychoanalysis and psychotherapy. The mother,

whose record is given by Flesch, had had three pregnancies in five
years. When pregnant the fourth time, she produced an abortion,
v hi cli v as followed by melancholia due to the fear of prosecution.

E delb erg and Galant describe as psychosis after therapeutic abor¬
tion several cases of psychogenic-depressive reaction, some of which
were followed by a hystero-epilepsy. They raise the question of the
value of such a therapeutic abortion done for mental disease. I was
forced to a similar conclusion from a recent experience in my own
practice: this patient developed a puerperal psychosis after her first
pregnancy, which confined lier to a sanitarium for seven months.
Marital conflicts ensued which delayed her mental recovery. A sec¬
ond pregnancy three years later, whose legitimacy was questionable,
bi ought up new conflicts. ( on.sulta.tion with a neurologist convinced
me that a therapeutic abortion might conceivably head off impending
psychosis, and that this was further justified by her irresponsibility
for maternal duties. This was done without complication, but two
months later a maniacal state developed, from which she has not yet
fully recovered.

A rare but interesting* sequela, to illegal abortion, due probably to
the unclean instruments occasionally employed, is the development
of pelvic actinomycosis. Hax cites the case of a chronic pelvic infec¬
tion following induced abortion, which after a year and a half led
to an abscess containing typical ray-fungus nodes. The patient died
months latei of pneumonia, and several encapsulated abscesses
were found in the abdominal cavity at autopsy, all of which showed
actinomycotic kernels. A similar history, with death from actinomy¬
cosis ten months after abortion, is recorded by Haselhorst. A poste-
lioi peifoiation of the cervix into the cul-de-sac was apparently the
method of implantation of the specific organism in this patient.

CHAPTER XIX

INDICATIONS FOR THERAPEUTIC ABORTION

IN THE CHAPTER on “ History of Abortion” attention was called
I to the practice in ancient times of therapeutic abortion to save
the life of the mother, and to the fact that one Greek school of
philosophy gave serious consideration to the eugenic indications.
In the early Christian era, toward the end of the fourth century,
a leading physician, Priscianus, recommended abortion to save the
life of the mother. As the influence of the Roman Church be¬
came more widespread, physicians were threatened with “ eternal
punishment” for taking the life of the unborn child and after the
tenth century medical treatises contain no mention of this subject,
nor was the question reopened for discussion, until the beginning of
the eighteenth century, and even then no note was taken of these
occasional papers until William Cooper in 1772, speaking of the bad
results of Cesarean section in cases of contracted pelvis, stated: “In
such cases, where it is certainly known that a mature child cannot
possibly be delivered in the ordinary Avay alive, would it not be con¬
sistent with reason and conscience, for the preservation of the mother,
as soon as it conveniently can be done, by artificial modus to attempt
to produce an abortion?”

American physicians were also liberal in their viewpoint. Dewees
in 1843 quotes with approval Alfred Velpeau who had said:

“For my own part, I confess I cannot possibly balance the life of
a foetus of three, four, five, or six months, a being which so far scarcely
differs from a plant, and is bound by no tie to the external world,
against that of an adult woman whom a thousand social ties engage
us to save ; so that, in a case of extreme contraction, if it were mathe¬
matically demonstrated that delivery at full term would be impossible,
I would not hesitate to recommend abortion in the first months of
gestation.” (From “Complete Treatise in Midwifery,” Meigs Trans¬
lation, 1852, p. 530.)

Hodge in his “Principles and Practice of Obstetrics,” while decry¬
ing criminal abortion (p. 301) as “one of those unnatural and horrible
violations of human and divine law which cannot be too severely
stigmatized and deserves condign punishment,” still advised induction
of abortion in cases of contracted pelvis where a viable child cannot
be born. The objection raised by Merriman and others that this might

277

278

ABORTION

lead to abuse, lie says, cannot be entertained, “for such objections
apply to all operations in surgery, and we cannot argue against the
use of a good agent because it may be abused. Neither should it be
regarded as an objection that the accoucheur may be requested to
induce abortion in the same woman in several successive pregnancies;
for he cannot allow the female to perish under his eye when the
means of preserving her life is in his power. ”

In England and France many obstetricians accepted this suggestion,
but in Germany it was not until the beginning of the nineteenth cen¬
tury that Kiwiseh, Scanzoni and others came out in favor of thera¬
peutic abortion. During the latter half of the nineteenth century the
indications, especially in Germany, were extended to include tuber¬
culosis, heart disease, nephritis and certain forms of psychosis, and
in the present century, particularly since the World War, there has
been an increasing tendency to extend the indications to eugenic and
social-economic factors. The literature in this field is enormous and
increasing yearly.

GENERAL INDICATIONS

As to the general principles which should guide us in determining
the question of whether or not a woman should be aborted, there is
bound to be some difference of opinion among physicians. A discus¬
sion of this sort in order to be scientific must be non-sectarian. Every
church, whether it be Christian, Jewish, Mohammedan or Buddhist,
that tries to regulate human conduct contrary to the laws of health
set up by medical science must eventually meet with failure. The
recent edict from Rome (Papal Encyclical, 1931) on the subject of
abortion limits the freedom of the Catholic practitioner and laity more
sharply than ever before. In practice, however, these strict regula¬
tions are not always rigidly enforced.

In general one might say that since the World War there have been
two movements running counter to each other. On the one hand
physicians have declared with increased evidence that certain ma¬
ternal conditions such as tuberculosis, heart disease, pernicious vomit¬
ing, etc., did not require therapeutic abortion as often as reports in
previous decades would seem to have indicated. The voice of this
conservative group has been worded by Winter as: “Not a single
abortion too many and not a single one too few. 99 In other words,
unless something were reasonably sure to be gained in the health of
the mother, the life of the child was not to be sacrificed.

The other group, represented by such men as Max Hirsch, are try¬
ing rather to extend the indications for therapeutic abortion, particu-

INDICATIONS FOR THERAPEUTIC ABORTION

279

iarly among the poor and ignorant by whom contraceptive measures
are usually inadequately employed. The disastrous social-economic
consequences of the War, necessitating the limitation of offspring at
all hazards, have led a group of honest and well-meaning physicians
to advocate an extension of therapeutic indications to eugenic fac¬
tors, to general debility, poverty and excessively large families. Some
have even gone so far as to advocate the Soviet system of legalized
abortion when desired by the mother, as better than the old laissez
faire policy. The bulk of the profession, however, is at present defi¬
nitely opposed to any such far-reaching extension of indications, and
in Russia, there is an ever increasing effort to reduce the practice,
since at best it subjects the woman to some immediate danger and
ultimately to the risk of considerable physical deterioration.

In general we may divide the indications for interrupting pregnancy
into those applying when the fetus is dead, and those when it is living.
In the former group the indication is certain and there can be little
argument except as to the best time for interference. Where the
fetus is living, we must distinguish between absolute indications, in¬
volving an immediate threat to the life of the mother, and relative
indications involving serious danger or harm to her health, even
though this may not eventuate until some years later.

If therapeutic abortion were limited to those cases where the life
of the mother was certainly and immediately imperiled, the number
of such abortions would be exceedingly small, and unfortunately they
would in many instances be done too late to save her life. It is fortu¬
nate therefore that the law in most civilized countries permits thera¬
peutic abortion on the basis not alone of immediate threat to the life,
but also of serious danger to the health of the mother. Leading gyne¬
cologists, such as Labhardt and Kiistner, strongly favor a limitation
of indications to medical conditions. In the 1932 edition of their
monograph “Kunstlicher Abort,” Winter and Naujoks emphasize that
the final decision on indications must rest with the obstetrician ; purely
social indications are to be banned, but social factors associated with
medical conditions demand careful consideration ; ignorance of heredi¬
tary factors makes eugenic reasons for abortion only exceptionally
permissible. Fairbairn writes cynically of the women in England who
favor social indications: “They would die — or would have us believe
so — if they produced families half the size of their grandmothers A”

The minor indications for therapeutic abortion give rise to the
greatest differences of opinion, according to Whitehouse, who enu¬
merates a wide range of conditions that have been claimed as justify¬
ing interruption: (1) very recent pregnancy; (2) general debility

280

ABORTION

with loss of weight; (3) after suppurative appendicitis that has pro¬
duced extensive adhesions; (4) after a previous Cesarean operation:
(5) to prevent increasing prolapse of the pelvic organs; (6) after
plastic repair of the pelvic floor to prevent a recurrence; (7) eugenic
reasons such as birth of a defective child or parental feeble-minded¬
ness ; (8) suicidal tendencies; (9) economic reasons in women of high
fertility; (10) previous postpartum infection; (11) co-existing malig¬
nant disease; (12) necessity of travel to remote regions where preg¬
nancy cannot be properly cared for.

In some countries, however, such as Austria and Czechoslovakia,
there is a tendency to permit greater freedom for induction of abor¬
tion. In Czechoslovakia, according to Yon Hentig, the indications
include not only; (1) danger to the life or health of the mother; but
(2) rape or punishable intercourse with girls under sixteen; (3)
danger of serious mental or physical disease in the child; (4) if the
mother has already three living children of her own, or has had five
deliveries, and if on account of external conditions more children can¬
not be reared properly.

In Italy, under the domination of Mussolini, there lias been a strong
movement to reduce the number of therapeutic abortions to a mini¬
mum. At the Italian Congress on Gynecology and Obstetrics in 1932,
Professor Cova discussed the medical indications for the interruption
of pregnancy, doubtless influenced by the prevailing Italian point of
view. He made sweeping statements to the effect that improvement
in medical service has reduced the indications to a minimum ; tuber¬
culosis no longer requires interruption of pregnancy. In hyperemesis,
goiter and cardiac disease, abortion may be justified, but only rarely.
Chronic nephritis constitutes a real danger and is an indication for
interference with the pregnancy. In chorea, psychosis, and various
nervous diseases, a pregnancy can usually go to term without en¬
dangering the patient. In cancer of the uterus, Cova considered
radium treatment preferable to hysterectomy, as it permits a con¬
tinuation of gestation (quite discounting the danger of congenital
deformities). In closing he said that, whatever the indications may
be, therapeutic abortion always constitutes a failure of medical science.
We must do our best, he declares, to see to it that in the future it may
be entirely abolished.

Of considerable interest in connection with the general indication
for interruption of pregnancy was the questionnaire on therapeutic
abortion sent out in 1930, to 1,266 doctors in Hamburg of whom 880
(70 per cent) answered. No signature was required by the physician
but usually this was given. Only 66, or 5 per cent, favored removing

INDICATIONS FOR THERAPEUTIC ABORTION

28]

altogether the restriction on abortion to medical indications; and
while 60 per cent opposed any interrupting for economic or social
indications alone, on the other hand 75 per cent favored giving social
factors due consideration in weighing the medical indications. The in¬
terruption of pregnancy in girls under sixteen years of age was
favored by 58 per cent, and 42 per cent were against it ; in the pres¬
ence of four or more children the vote stood 32 favorable, 16 condi¬
tional, and 52 opposed. On the question of aborting women who
became pregnant after they were 40 years of age, the vote stood 44
per cent favorable, 56 per cent opposed. The conservatism of the
German medical profession is sufficiently manifest by this vote.

A similar report on a smaller scale was made in 1930 by J. C. Ayres
from a questionnaire sent to 62 obstetricians living in the southern
United States. Indications for therapeutic abortion were denied in
most instances :

Yes No

For social reasons to prevent disgrace _ in 51

For economic reasons, poverty _ G 56

For health reasons (life not involved) _ 22 37

To save the mother’s life _ 61 1

In cases of rape _ 36 20

For dominant hereditary taint in both parents _ 21 34

Frequency. — Statistics, which are available in largest numbers from
German sources, indicate a steady growth in the percentage of cases
demanding therapeutic abortion. Twenty years ago Fritsch reported
only one therapeutic abortion in 10,000 pregnancies, Ahlfeld one in
25,000, and Winkel as low as one in 100,000. But in these same clinics
at the present time the ratio of therapeutic abortions to pregnancies
is about one in 1,000, and in some clinics even as high as one in 400
pregnancies.

Of the conditions justifying this procedure tuberculosis still remains
by far the most frequent cause. Out of 100 therapeutic abortions done
by Goldschmidt in Breslau the indication in 81 cases was tuberculosis
of the lungs; in 3 cases, laryngeal tuberculosis; in 11 cases, heart
disease; and in 3 cases contracted pelvis. Nanjoks has tabulated
the therapeutic abortions from Konigsberg in 1917, Giessen in 1920,
Munich in 1925, and Frankfurt in 1925. He found that out of a total
of 287 therapeutic abortions, 209 were done for tuberculosis of the
lungs, or larynx, 34 for heart disease, 15 for kidney disease, 14 for
psychosis, 9 for hyperemesis and 6 for contracted pelvis.

Pawlova cited the indications in 25 cases as tuberculosis 15 times,
heart disease 4 times, blindness twice, nephritis once, and miscellaneous
3 times. Superbi reports 15 out of 22 cases of therapeutic abortion
done for tuberculosis. In Rome, S. Russo reported the causes of 281

282

ABORTION

therapeutic abortions in 29,501 pregnancies. The percentage distribu¬
tion. was : for tuberculosis, 38 ; for nephritis, heart disease and toxemia,
each 10 ; pyelitis, 0.5 ; and all other indications, about 30. The indi¬
cations in 162 cases analyzed by Spitzer in Prague were : tuberculosis
87, heart disease 23, psycho-neurologic conditions 13 ; pregnancy tox¬
emia 10; eye diseases 7; asthma 5; endocrine disorders 9; various
other diseases 8.

The improved treatment of hyperemesis has reduced considerably
the frequency of interruption for this condition. Out of 69 cases
Heynemann was compelled to abort only three. W. J. Dieckmann and
R. J. Crossen, Washington University, St. Louis, reported that, where¬
as from 1917-1921 there were 6 therapeutic abortions in 11 cases of
hyperemesis, from 1921-1927, 48 cases of hyperemesis had been treated,
with intravenous glucose administration without the necessity of a
single abortion. Additional figures on frequency will be found under
the head of special indications. In the following summary these re¬
ports are listed, showing that tuberculosis was the indication in 54
per cent of the women.

Indications For Therapeutic Abortion

REPORTED BY

TOTAL

TUBER¬

CU¬

LOSIS

heart

KIDNEY

ILYPER-

EMESIS

NERVOUS

AND

MENTAL

CON¬

TRACTED

PELVIS

OTHERS

Goldschmidt

100

Naujoks

287

209

Pawlova

2,5

Superbi

Russo

100

Spitzer

162

496

268

Group Indications

I have in part followed Winter’s analysis of the indications for
therapeutic abortion with certain minor changes evident from the
following outline. The two main groups are differentiated according
to whether the fetus is dead or still living.

A. Bead fetus, (mole, missed abortion)

B. Living fetus

(1) Diseases of the ovum

(2) Pregnancy toxemias

(3) Complications at labor

(4) Diseases of the genital tract

(5) Systemic diseases (tuberculosis, heart disease, kidney, blood,
skin, syphilis)

(6) Endocrine diseases

INDICATIONS FOR THERAPEUTIC ABORTION

283

(7) Diseases of the nervous system, organic and functional

(8) Diseases of special organs (eye and ear)

(9) Other unclassified diseases

(10) Rape

(11) Eugenic factors (hereditary disease, insanity, epilepsy)

(12) Social-economic indications.

A. DEAD FETUS

There is some room for argument as to whether the emptying of the
uterus in case of the death of the fetus is properly to be designated
by the term of therapeutic abortion. While in the large majority of
cases the ovisac will be expelled spontaneously within a few weeks
after the death of the fetus, there is nevertheless a notable number
in which this does not come to pass unaided. The number of cases
of missed abortion is quite considerable, and if greater attention
is paid to the history, it will repeatedly be found that the develop¬
ment of the ovum does not correspond to the duration of the preg¬
nancy. In cases of hematoma or Breus mole the ovisac may be re¬
tained as long as fourteen months.

The Aschheim-Zondek test is of great help in establishing the diag¬
nosis of fetal death. It has been definitely found that anywhere from
seven to ten days after fetal death a test which was previously posi¬
tive becomes negative, unless the fetal membranes continue to grow
because of some pathological condition, such as hydatid mole.

Occasionally there may be irregular uterine bleeding with a few
cramplike pains, but without expulsion of the ovisac. In other cases
the woman has been told that her child has ceased to develop and is
insistent upon the evacuation of the uterus as quickly as possible. The
physician while justified in taking measures to bring on an expulsion
of the ovum, is not justified in the use of measures likely to prove
dangerous to the woman in any degree. It should be remembered in
this connection that a uterine muscle, so sluggish as not to expel its
contents spontaneously, is apt to require more than the usual amount
of medical and mechanical stimulation to react as desired.

B. LIVING FETUS

(1) Diseases of the Ovum

These can be grouped under four heads : Hydatid mole ; placental
hemorrhage in the first half of pregnancy; hydramnios; and injuries
to the fetus from x-ray or radium.

284

ABORTION

Hydatid mole Avill in almost all instances be associated with fetal
death, but in the presence of a positive Aschheim-Zondek this cannot
readily be determined. The diagnosis, resting on bleeding during the
first months of pregnancy, associated with rapid growth of the uterus,
can be made positively even without the passage of the typical grape-
like bodies. In view of the relatively high incidence of chorioepi-
thelioma following this mole, its treatment as a premalignant condi¬
tion is justified and hence steps should be taken to empty the uterus
at the earliest possible moment after the diagnosis has been estab¬
lished. It should, however, be kept in mind that the dangers both of
infection and perforation are greater than in the case of an ordinary
abortion. There is little difference of opinion as to the indication in
such a case.

More dubious are other conditions that produce bleeding during
pregnancy, since in many instances its cause is undetermined. In a
certain number bleeding will be found to be due to a low position of
the placenta (placenta praevia), in other instances it is probably trau¬
matic. External causes such as cervical polyp or carcinoma must be
excluded, and only when the uterine bleeding has progressed to the
degree of producing some anemia are we justified in active interfer¬
ence by abortion. If a negative Aschheim-Zondek points finally to
fetal death, a prompt evacuation of the uterus is indicated to check
the bleeding. Winter states that if the hemoglobin index has dropped
below 50 per cent, interruption of pregnancy is permissible.

Hydramnios will not often be a factor in justifying abortion in the
first half of pregnancy. Between the fifth and seventh month, how¬
ever, the acute form of hydramnios associated almost entirely with
multiple pregnancy may give rise to such rapid distention of the ab¬
domen that it would not be safe to permit the pregnancy to continue.
Gyulai reports an interesting case of quadruplets of four months’
gestation in which there was a sudden increase in the size of the uterus
with circulatory upset which did not improve under rest and required
therapeutic abortion for its relief. The four fetuses in this case were
all in one chorion. More frequently these cases develop after viability
of the fetus and therefore need no consideration here.

Injury from Radiation. — As the use of radium and x-ray in large
doses for the treatment of cancer and myoma becomes more common,
we are faced with a new indication for the interruption of pregnancy.
The object here is not so much to help the mother as to prevent the
birth of a microcephalic idiot or other monstrosity. The careful
analysis of Murphy brings convincing evidence of serious fetal injury
following in a large proportion of cases that are subjected to exten-

INDICATIONS FOR THERAPEUTIC ABORTION

285

sive pelvic radiation during early pregnancy. Indeed the fact of this
injury is taken advantage of in the nonsurgical method of abortion
by x-ray in early pregnancy. It is therefore claimed that whenever,
by mistake or necessity, a pregnant uterus has been subjected to
heavy radiation, it is unwise to permit the child to continue develop¬
ment as it is reasonably certain to turn out to be an idiot or deformed.
This is one of the most positive of the eugenic indications and might
perhaps be grouped under that head, although it has seemed to me
rather a direct injury to the ovum. A few voices have been raised
against this viewpoint, as E. Sachs, who believes that the possibility
of malformation does not justify abortion after x-ray any more than
the possibility of inherited taint in alcoholic parents justifies it. The
consensus of opinion, however, is that if a radium treatment of over
1,500 milligram hours, or its equivalent in x-ray, has been applied
to the pelvic organs within the first five months of gestation, the
assumption of serious fetal damage is so great that the pregnancy
should be terminated.

(2) Pregnancy Toxemias

Pregnancy toxemias are an important group with varying mani¬
festations that not infrequently require abortion to serve the best
interests of the mother. They include hyperemesis, chorea, acute yel¬
low atrophy of the liver, and preeclamptic toxemia. The first three
conditions are usually found in the first half of pregnancy when
interruption would be of some benefit ; but preeclamptic toxemia can
ordinarily be treated conservatively, and only in rare instances will
an interruption of pregnancy before viability be justified.

Hyperemesis is so important a complication that it deserves special
consideration. According to Williams, we must distinguish between
a reflex or neurotic type, and a toxic type of hyperemesis. The former
is usually mild and can be corrected by various simple measures. Only
occasionally in obstinate reflex-neurotic cases do we find that pro¬
longed starvation produces changes in metabolism resulting in a true
toxemia. The toxic form, particularly if it has been permitted to gain
headway without treatment for some time, presents a very different
clinical picture. The loss in weight is rapid as the patient is unable
to retain any food by mouth. Repeated enemata of glucose and the
intravenous administration of glucose solution in large amounts will
as a rule result in gradual improvement of the patient’s condition.
All such patients should, of course, be hospitalized, if the desired
result is to be obtained. The experience of all large clinics has been
that, if the case is admitted early and glycogen balance restored

286

ABORTION

promptly, no serious damage is done, and abortion will not ordinarily
be indicated. It is for this reason that we find relatively far fewer
cases of hyperemesis requiring abortion in the large maternity insti¬
tutions than in the average run of private practice. Furthermore,
there is no doubt that a considerable number of cases are aborted that
would not have required such radical measures, had they been placed
in suitable institutions under the latest treatment for this condition.

On the other hand the attempt to be conservative, and to limit
therapeutic intervention to the really serious cases, can be carried too
far, as is shown in recent reports from many large clinics.

There is considerable variation in the frequency with which this
indication has been set. Heynemann in 69 cases of pronounced hyper¬
emesis at Hamburg and Halle was compelled to resort to therapeutic
abortion only three times, all patients surviving. Benthin in 68 cases
resorted to abortion fifteen times with several deaths; and he also
cites a case in which abortion had to be repeated seven times in the
same woman for hyperemesis. Davidson at the maternity hospital in
Edinburgh between 1923 and 1927 did 18 therapeutic abortions for
hyperemesis with 8 deaths.

The difficulty lies in deciding just when the abortion is positively
indicated. A delay of one or two days at this point may be very vital
to the patient. Naujoks has recently directed attention to the sig¬
nificant clinical and laboratory findings upon which this decision must
rest. There is a general agreement that mere loss in weight, even up
to twenty or twenty-five pounds, does not justify interference. Nor
can the presence of a rapid pulse, a dry tongue and fetid breath be
considered as definitely dangerous symptoms. All of these may clear
up rapidly in a few days under treatment with sedatives, rest in bed
and glucose intravenously.

Winter has stressed the following symptoms: (1) irregular pulse;
(2) elevation of temperature to 39° C. (102° F.) or more; (3) albu¬
minuria; (4) cerebral symptoms such as restlessness, mental hebetude,
or semi-coma; (5) icterus of light degree; and (6) disturbances of
general physical condition, as shown by prostration, fainting, collapse.
Benthin emphasizes the cessation of vomiting with rapid pulse and
elevated temperature, especially if associated with restlessness, as an
ominous sign. Frey considers Winter’s indications too wide, and as
a result of certain laboratory tests has been able to reduce the num¬
ber of cases requiring abortion. On the other hand Bupp stresses the
fact that in a number of cases proceeding fairly normally, there may
be a sudden exacerbation of the vomiting so severe that in spite of
immediate abortion the patient cannot be saved. Gauss emphasizes

INDICATIONS FOR THERAPEUTIC ABORTION

albuminuria and cylindruria as alarming signs of kidney destruction.
In our own recent observations at the Saint Louis Maternity Hospital,
neuritis, optic neuritis and psychic disturbances indicating progres¬
sive toxemia have been occasionally noted, and these have served as
an indication for therapeutic abortion.

Heynemann and Naujoks call attention to the importance of certain
laboratory tests, in addition to the general clinical picture, as a basis
for arriving at a decision. The presence of large amounts of ketone
in the blood demands serious consideration. Less important are the
liver function tests which are made complex by pregnancy metabo¬
lism. Of considerable value is the bilirubin test. Heynemann finds
that increase of bilirubin in the blood up to 2 milligram per cent
makes a very serious prognosis for the patient and should justify in¬
terference, if corroborated by the clinical picture. Recently Somaghi
has simplified the determination of blood diastase as an index of liver
damage. It may prove of great value.

To summarize then, therapeutic abortion is indicated in liyperemesis
in the presence of temperature elevation, 1+ albumin with casts (if
urine has been normal before), an irregular rapid pulse with pro¬
nounced prostration, or pronounced toxic symptoms in the nervous
system such as optic neuritis, polyneuritis and psychic manifestations.
If the patient has been under the recognized treatment for her hyper¬
emesis and such symptoms do not clear up promptly it is better not
to delay the interruption of pregnancy. Even so, it should not prove
necessary to interfere in over 5 to 8 per cent of the severe cases of
hyperemesis, provided the patient can be hospitalized or be under
skilled care at home.

Chorea. — Chorea of pregnancy appears in two different forms ; one
as a recurrence of chorea in childhood, and the other appearing for
the first time during pregnancy. The recurrence of a pre-existing
chorea is brought about by the increased irritability of the nervous
system in the pregnant woman. We usually do not find serious com¬
plications in this form, and an interruption of pregnancy is therefore
rarely indicated.

The other form is definitely toxic in origin and has a bad prognosis.
Pineles found about 17 per cent maternal mortality in these cases.
The greatest danger exists from an extension of the twitching to the
muscles of the eosophagus and the trachea, thereby producing an in¬
spiration pneumonia. Complication with cardiac decompensation and
psychosis also gives a bad prognosis. These complications justify
interruption of pregnancy as do also those presenting definite indica¬
tions of toxemia. Winter also advised interruption of pregnancy

288

ABORTION

where chorea has existed in previous pregnancies and recurs a second
time. Even interruption of pregnancy does not give relief in more
than a small percentage of cases. According to Pineles there were 27
deaths among 55 women upon whom therapeutic abortion had been
done for a severe chorea.

Icterus. — Acute yellow atrophy of the liver according to Levy-Lenz
occurs in the first months of pregnancy and presents very serious
symptoms. Tenderness over the liver, a reduction in size of this organ,
intense icterus, with the onset of mental derangement, justifies im¬
mediate intervention. It is better to abort before such serious symp¬
toms have developed. Prolonged icterus in the first half of pregnancy
requires careful observation and in case of positive findings of hyper¬
bilirubinemia requires therapeutic abortion to save the life of the
mother.

Nephropathy. Under the head of nephropathy, edema of preg¬
nancy, and eclampsia, are to be grouped cases in which the kidney
function is so seriously disturbed that interruption of pregnancy is
often indicated. Since, however, the vast majority of these cases do
not arise in the first half of pregnancy their consideration under the
head of therapeutic abortion can be dismissed with relatively few
words. Edema in itself does not justify interruption, nor does the pres¬
ence of albumin and casts. More serious are such complications as pre¬
mature detachment of the placenta, and eye symptoms such as amauro¬
sis, retinitis albuminuric a and ablatio retinae. If such symptoms pre¬
sent themselves from the fourth to the sixth month of pregnancy as
occasionally happens, we are justified in almost every instance in
promptly interrupting the gestation, without awaiting viability of the
fetus. "Whei e some kidney damage is left over from a preceding preg¬
nancy an earlier interruption in the presence of kidney disease is
often indicated. These cases will be given further consideration
under the head of chronic nephritis.

(3) Complications of Labor

While the first therapeutic abortions were done for contracted
pelvis, and while this indication persisted during the period when
Cesarean section had a 20 to 30 per cent mortality, present conditions
no longer justify this procedure. Winter puts the situation graphi¬
cally in the following way : 100 Cesarean sections would have about
2 per cent maternal mortality and 3 to 5 per cent fetal mortality ; 100
artificial aboitions would have no per cent maternal mortality and
100 pei cent fetal mortality. By artificial abortion, therefore, we

INDICATIONS FOR THERAPEUTIC ABORTION

289

would sacrifice the lives of 95 children for the sake of saving 2
mothers. Practically without exception obstetricians would agree
that this is not justified.

In place of therapeutic abortion, premature induction of labor has
been advised in many cases where the mother’s condition would make
a laparotomy a more serious procedure. Henkel does not favor en¬
tirely discarding contracted pelvis as an indication for therapeutic
abortion. He says that an occasional case complicated by unfavor¬
able social conditions (large family, poverty, poor physical condition
of mother) would seem to justify interference. In the case of tumors
blocking the pelvis surgical intervention at the end of pregnancy is
preferable to abortion. In those women in whom extreme narrowing
of the vaginal canal or excessive scar tissue make a delivery danger¬
ous, abortion would be contraindicated because of the difficulty of ap¬
proach from below.

(4) Diseases of the Genital Tract

Malposition. — In certain types of misplacement of the uterus we
may have the question of interruption of pregnancy put before us.
With but very few exceptions the adherent retro verted uterus will
loosen up in pregnancy so that with the assistance of certain vaginal
manipulations the fundus can be lifted out of the hollow of the sacrum
and the pregnancy permitted to proceed. In rare instances, however,
the uterus is so densely adherent as to make this impossible. It is
better to loosen such an incarcerated uterus by laparotomy from above
than to proceed with the difficult and dangerous job of emptying a
three or four months’ pregnancy through a cervix whose position
at this time would be high above the symphysis.

Somewhat different is the situation in those cases where a preg¬
nancy has taken place, by reopening of tubes after attempted sterili¬
zation following an interposition operation. Here the uterus is in ex¬
treme anteflexion and the fundus, readily accessible from below, can
be evacuated by an anterior hysterotomy. At the same time a high
amputation of the uterus can be done from below to insure against
further pregnancies.

Complete prolapse with its considerable danger of infection up¬
ward from the exposed cervix is an indication demanding serious
consideration (Fig. 115). H. Beck favors interruption of pregnancy
in many of these cases. Having personally lost a patient through such
an infection of a pregnant prolapsed uterus I would be inclined to
favor interruption whenever, in spite of prolonged bed rest, there is
a recurrence of the prolapse.

290

ABORTION

Myoma. Tlie many complications attendant upon myoma of the
uterus associated with pregnancy have led most men to proceed with
a hysterectomy regardless of the pregnancy, whenever the tumors are
laige or so situated as to render the further progress of the pregnancy
dangerous. Spontaneous abortion occurs in many of these cases, and
through the increased tendency to hemorrhage and retained placenta,
and the difficulty of access to the uterine cavity, the subsequent treat¬
ment is rendeied difficult. A sacrifice of the uterus in the interest of
the mother would, therefore, be justified in many instances (Fig. 116).
At times, particularly if it be the first, and possibly the only, preg-

pig\ 115. Prolapse of the pregnant uterus following rupture of the vesico-uterine
septum. (Redrawn from Henkel: Zentralbl. f. Gynak., 1929.)

nancy after many years of married life a myomectomy with preserva¬
tion of the uterus can be done. Therapeutic abortion alone is danger¬
ous in a myomatous uterus and practically never indicated. A similar
dictum applies to cases of cancer of the cervix complicated by preg¬
nancy. Here therapeutic abortion would lead to considerable danger
of infection of the placental site from the cancerous cervix. We must,
therefore, proceed in these cases promptly with the treatment of the
cancer by surgery or radium regardless of the existing pregnancy.
Only very exceptionally where the cancer is not diagnosed until
toward the last month or two of pregnancy, and is at that time too

INDICATIONS FOR THERAPEUTIC ABORTION

291

Fig-. 116. — Multiple myomata of the uterus complicated by pregnancy and requiring
hysterectomy. (Kelly-Cullen : Myoma of the Uterus.)

far advanced for any hope of cure, is it permissible to await the termi¬
nation of pregnancy by Porro-Cesarean section in the interest of
the child.

Diseases of the adnexa are rarely complicated by pregnancy with
the exception of ovarian tumors. These cases are usually handled by

292

ABORTION

surgical removal rather than by emptying the uterus so that they do
not demand consideration in this chapter. Small retention cysts de¬
veloping during pregnancy may be expected to resolve spontaneously.
An ovarian dermoid with its danger of infection, a fibroid low in the
uterus on the posterior surface, or otherwise threatening impaction or
serious interference with labor is reason for interruption. The com¬
parative risks should be stated to the family and the ultimate decision
be theirs. A freely mobile ovarian cyst is quite prone to torsion of
the pedicle after delivery, and its removal early in pregnancy may be
desirable. The moderate-sized fibroids, located high, grow in preg¬
nancy, but unless multiple and thus threatening postpartum hemor¬
rhage, call only for watching.

Winter mentions a few rare cases of endometritis with persistent
seveie hemorrhage that may necessitate in a few instances emptying
of the uterus in order to check the growing anemia. Most of these
cases will, of course, abort spontaneously but should this for some
reason not occur the emptying of the uterus would seem to be indicated.

(5) Systemic Diseases

Tuberculosis of the Lungs. — The most significant indication for
therapeutic abortion, in point of frequency, is tuberculosis of the
lungs. The common observation that a tubercular process grew
markedly worse in the course of a pregnancy and in the periods of the
puerperium and lactation, led, at the beginning of this century, to the
almost unanimous opinion that patients who showed any evidence of
tuberculosis should be advised against pregnancy, and in the event of
a gestation should be aborted without fail at the earliest possible mo¬
ment. In the past three decades, however, more careful observations,
and especially the reports from tuberculosis senatoria, have greatlv
modified this viewpoint. At present there is general agreement that
every case should be most carefully studied from all angles, social as
well as medical, and that interference with the pregnancy is only
justified in certain well-defined circumstances.

In the first place every patient should be studied closely for a
period of three or four weeks. This consists of regular four-hour
tempei atures, frequent recording* of weight, presence of tubercular
bacilli m the sputum, general condition, as well as repeated physical
examinations of the chest, to determine as accurately as possible
whether the process is latent, active or progressive. Such observa¬
tions are obviously not in the province of the obstetrician. He must
call in foi advice an internist or the family physician. Owing to the
difficulties of accurate diagnosis, it will be better to seek the advice

INDICATIONS FOR THERAPEUTIC ABORTION

293

of the former, wherever possible. Even trained specialists in tuber¬
culosis will not always agree exactly as to the findings, but such oc¬
casional differences of opinion do not justify skepticism as to the
value of their diagnosis. Obstetricians must rest their decisions
largely on the reports rendered by their consulting internists. This
does not mean that the obstetrician is to follow blindly their order
to abort a patient. As I see it, the duty of the internist is to answer
the following questions: (1) Has the patient tuberculosis? (2) Is
this tubercular process latent, active or progressive? (3) Has the
tubercular process in the course of the three or four weeks of obser¬
vation and treatment shown a tendency to regress or advance?

AVith this evidence before him, and with a knowledge of the social
circumstances of the particular case (poverty, number of children,
possibility of sanatorium treatment), the obstetrician must decide in
the light of our present experience whether to proceed with the abor¬
tion, to await further developments, or to let the pregnancy proceed
to its termination. It is the duty of the obstetrician to know which
group of cases should be left alone and which ones should be aborted.
Many an internist may correctly diagnose the lesion but not be fa-
miliar with the indications for interference. In fact there is general
complaint that the internist who does not appreciate the dangers and
sequelae of instrumental abortion, is too apt to recommend it when
there is no absolute necessity.

The gradual limitation of indications for interference has been
partly the result of more accurate methods of diagnosis, partly due
to improved methods of treatment, such as absolute rest in sanatorium
and the use of artificial pneumothorax, and partly the outcome of a
more careful follow-up of cases after abortion and after full-term
pregnancy pointing to the questionable value of interference in many
cases.

Latent cases of tuberculosis are generally regarded as not justifying
interruption of pregnancy. While there is no absolute guarantee that
a latent case will not from time to time flare up in a more active
form, this will happen but rarely when the patient has been kept un¬
der close observation, and prophylactic rest and prompt treatment
instituted on the first evidence of suspicious symptoms. Moreover,
the abortion will in itself at times have an unfavorable influence on
a latent tuberculous lesion.

The apical form is generally conceded to be more benign and hence
amenable to treatment, so that in such lesions, according to Klemperer,
Doederlein and others, abortion should not be performed.

294

ABORTION

In active manifest tuberculosis interruption is recommended by
Winter, since six out of seven cases grow worse during pregnancy.
Winter would advise abortion in every case of persistent fever defi¬
nitely due to the tuberculosis, and in every woman whose sputum
shows tubercle bacilli, but not in cases of weight loss or hemoptysis.
Klemperer considers the early exudative type of tuberculosis and the
piesence of a cavity as suitable for therapeutic abortion. On the other
hand, we have the extremely conservative view of Mayer and Menge
who believe that no benefit is derived from abortion even in these
cases, and that it should, therefore, only rarely be done. I doubt
whether such an extreme position is justified, even though Schultze-
Rhonhof fiom Menge s clinic, found that out of 44 cases of clinically
manifest tuberculosis in which pregnancy was allowed to go to termi¬
nation, subsequent observations over a period of five years showed 21
improved, 10 unchanged, 6 worse and 7 dead. Scherer also found that
cases often did better when abortion was refused for some reason,
than those cases upon whom it was done.

The bulk of evidence, however, points to a definite value of thera¬
peutic abortion in active or progressive cases of tuberculosis. Thus
Winter reports 167 therapeutic abortions before the sixteenth week
with 145 favorable results (8/ per cent). Kelirer saw improvement
m 80 to 90 per cent. Cambiaso in Genoa found that while out of 105
tuberculous patients in which pregnancy was allowed to go to term
9 per cent were alive after 10 years, out of 85 cases in whom abortion
was done 33 per cent were living. Norris and Murphy found 65 to 70
per cent improvement as a result of abortion.

In a study of the obstetric histories of 484 patients treated at the
Trudeau Sanatorium, Matthews and Bryant (1931) found that of all
women who became pregnant before “cure,” 44 per cent noted that
their lung condition was adversely affected by the pregnancy. In the

80 artificial abortions reported by these patients, no bad after-effects
were noted. They conclude :

(1) Pregnancy has a definitely deleterious effect on tuberculous
women.

“(2) The more advanced the tuberculosis, the more deleterious the
effect of pregnancy.

(3) The women who took sufficient time before getting pregnant
after being 4 cured ? (three years or more), and who obeyed all rules

and regulations after leaving Trudeau, fared better than those who
did not.

INDICATIONS FOR THERAPEUTIC ABORTION

295

“ (4) Out of the 579 children born, 556 are alive, and 501 are healthy
and well. Fifty-five are below par, and only 9 of these have had tuber¬
culosis in any form, or have been suspected.

“(5) Education of the patient in the care of herself as regards
tuberculosis as well as pregnancy is of the utmost importance.

“(6) Finally, the whole subject is a difficult one; experiences dif¬
fer, there are many opinions. To pursue the right one, doing justice
to the mother, to the child, and to the other members of the family,
demands most careful thought, the exercise of the keenest judgment.
Sanatoriums, clinics, floating hospitals and rest homes have been pro¬
vided for all ages and conditions of patients except pregnant women.
Intelligent guidance through pregnancy, scientific supervision of the
labor and puerperium, with proper care of the child and sanatorium
treatment for the mother, should be the management of all such cases.”

In a study made by Jennings, Mariette and Litzenberg of 27 tuber¬
cular women six months postpartum, it was noted that while one died
and three became worse, the vast majority were not unfavorably af¬
fected. Those with minor lesions in the lungs were unharmed by
pregnancy or labor. Hence, while advising against a pregnancy in
tubercular women, the authors believe that when conception has oc¬
curred, such women can with due care and under favorable conditions
be safely carried through their pregnancy.

In a recent discussion on the indications for therapeutic abortion
in tuberculosis, Pottenger emphasized a study of factors such as cho¬
lesterol, calcium deficiency and absence of allergy reaction that
might indicate decreased resistance to the disease. If the tuberculosis
is active, and is discovered previous to the third month, and if the
patient is unable to be kept under observation, he advises abortion.

Evidence is undisputed that if abortion is done early, it is less
dangerous and the final result is more favorable than if done late. Thus
Winter found that, while 87 per cent of 167 cases aborted between
the second and fourth months showed improvement, only 51 per cent
of 99 abortions between the fifth and seventh month and only 25 per
cent of 36 inductions of labor from the eighth to tenth month showed
favorable reaction. On the other hand, this should not be interpreted
as demanding immediate intervention, for experience has shown that
a study of several weeks with suitable treatment may lead to the con¬
clusion that abortion is not required. Furthermore, evidence from
other sources does not confirm the harmful effect of the last months
of pregnancy on the tuberculosis ; rather does it seem that the fixation
of the diaphragm at such times may have a favorable effect similar to
that of an artificial pneumothorax.

296

ABORTION

Especially does the consistent and prolonged treatment of these
women in sanatoria, or, even better, under treatment in a special divi¬
sion of: a maternity hospital, lead to strikingly favorable results. The
experience of the past ten years according to Bauer has conclusively
proved the value of such treatment in arresting the disease in active
lesions complicated by pregnancy. Treatment at home is rarely satis¬
factory. In fact such patients must get absolute bed rest for long
periods of time throughout the pregnancy. In addition to this, the
more extended use of artificial pneumothorax in suitable cases has
greatly diminished the number of cases requiring interference.

Such prolonged sanatorium treatment is, however, not always
feasible. On the one hand, as Scherer points out, it may lead to fam¬
ily dislo\ ally ; on the other hand, it may for social or economic rea¬
sons be impossible. In fact the question of therapeutic abortion in
tuberculosis of the lungs is intimately bound up with the social-
economic status of the patient. In a poorly nourished woman with a
laige family, we must regard the saving of fetal life with less concern
than in the woman who can and will carry out sanatorium treatment
for the required period of time during and after her pregnancy, and
foi w^10m the saving of the child is a matter of great concern. In
such women with but one or no children we may, even in active cases,
lefrain from intervention, while in those whose external conditions
make the pregnancy and the subsequent care of the child a serious
burden,, we would incline more readily, even in latent cases, to an in¬
terruption. Unfortunately this ideal sanatorium treatment of the
tuberculous pregnant woman is for economic reasons available for but
a relatively small number of persons, so that we must resort to thera¬
peutic abortion in the majority of cases that are not definitely quiescent.

Laryngeal tuberculosis as a complication of pregnancy demands
special consideration because of the common experience that it be¬
comes more active at such time and leads to a fatal termination. Of
231 cases collected from the literature by Lobenstine, 200 died dur¬
ing pregnancy, in labor, or soon after, a mortality of 86 per cent.
Non is has found it usually associated with active lung tuberculosis
and seriously complicated by pregnancy. There is a general consensus
of opinion that abortion is indicated in laryngeal tuberculosis, even
though the final outcome is fatal in a considerable percentage of
cases. If between 85 and 90 per cent of these women die when preg¬
nancy is allowed to continue to term, abortion may be said to have a
favorable effect, if it reduces the mortality to 54 per cent, as indicated
by Winter’s statistics.

INDICATIONS FOR THERAPEUTIC ABORTION

297

We find Menge and Mayer taking a skeptical view of the value of
therapeutic abortion in these cases. The swing away from abortion
in laryngeal tuberculosis in recent years is most strongly presented
by the careful report of Karl Fink (1931). Doubtless better methods
of diagnosis and treatment have had their bearing on therapeutic in¬
dications. Fink’s collection of 131 cases showed 33 per cent in which
the tubercular lesion was relatively benign and in which abortion in
his opinion was not justified. On the other hand, the far advanced
cases could no longer be benefited by any such measures. This leaves
a greatly reduced number of instances in which he felt that such
measures were of benefit. The marked improvement in the treatment
of laryngeal tuberculosis with tracheotomy, the Finsen light and sana¬
torium care has caused a drop in the death rate from 90 to 50 per
cent. Fink differentiates between the circumscribed and the diffuse
ulcerative lesions. The former can under proper treatment be healed
or kept within bounds in spite of the pregnancy. The latter will
often require a termination of the gestation. Such therapeutic inter¬
ference should if possible be done in the early months of gestation,
since it is of practically no value if performed after the sixth month.

To summarize, then, it would seem reasonably certain that :

(1) Pregnancy has an unfavorable effect on tuberculosis.

(2) Latent tuberculosis does not justify interruption.

(3) Active or progressive tuberculosis is an indication for inter¬
ference.

(4) Therapeutic abortion, in two-thirds or more of these cases, will
diminish the harmful effects of the pregnancy on the tubercu¬
lar process.

Diseases of the Heart. — Recently a tendency toward greater conser¬
vation lias also been manifested with regard to the indications for
therapeutic abortion in women with heart disease. Yet we find that
many internists are unwilling to accept the additional risks entailed
by a waiting policy. The difficulties of predicting whether the heart
muscle will be able to withstand the added strain of pregnancy, labor
and the postpartum changes are very great. It would seem, there¬
fore, that here, too, as in the case of tuberculosis, we must give serious
consideration to the social factors, the number of children, etc., in our
decision whether the added child is worth the added risk to the
mother’s life.

In heart disease we are faced with a threefold danger: (1) the
strain upon the circulatory system by the pregnancy itself; (2) the
effect of the labor with its unavoidable physical exertion; (3) the
sudden change in intra-abdominal pressure immediately following de-

298

ABORTION

livery with its increased risk of embolism and sudden heart failure.
Even where the first of these conditions is causing no visible disturb¬
ance, we cannot be certain of the effect of the other two.

Nevertheless it must be stated that the majority of cardiac cases
will not require interruption of pregnancy, provided the family cir¬
cumstances are such that the required rest and convalescence after
delivery are feasible, and the care of a child or an additional child
will not be likely to overburden a defective heart. Aortic lesions and
mitral insufficiency will, with careful supervision to avoid undue exer¬
tion, necessitate no interference. Mitral stenosis on the other hand gives
a more serious prognosis. Here we must differentiate between the mild
cases that give but slight, if any, signs of cardiac decompensation, and
the severer ones with definite early impairment of the myocardium.
Most internists (according to Levy-Lenz, fifteen out of twenty-five)
are agreed that all such severe cases of mitral stenosis should be
aborted as early in pregnancy as possible. According to Traugott and
Kautsky, seven out of eight cases of mitral stenosis become decompen¬
sated in pregnancy with a mortality of 28 per cent. This is particu¬
larly true of women over thirty-five years of age who have had several
children in close succession. Failure of cardiac compensation that
does not promptly yield to digitalis justifies interruption; the more
so, because, as Da Maggio points out, the dyspnea , edema and albu¬
minuria, attended as they are by accumulation of C02 in the blood,
cause fetal death in a large number of cases. In cases of marked de¬
compensation, however, it is better to delay the therapeutic interven¬
tion until the patient’s condition has been somewhat improved by
treatment. According to Dame Annie Louise Mcllroy, the abortion
itself may occasionally have an unfavorable effect upon the heart
condition.

In myocarditis, according to Levy-Lenz, the indication for early
therapeutic abortion is always present. Only when the condition is
not recognized until after the fifth month is a waiting policy justified.
The prognosis even with abortion is unfavorable. Interference is also
advised in cases of recurrent endocarditis after angina or polyarthritis,
merely waiting for a favorable moment after the acute symptoms have
subsided.

Kypho-scoliosis complicated by pregnancy is apt to cause such abnor¬
mal conditions of intra-abdominal and intra-thoracic pressure that the
heart is seriously affected. Fortunately a large percentage of these
women miscarry but among those that go to term the incidence of sud¬
den death following delivery is very great. For this reason Levy-
Lenz advises theiapeutic abortion m these women on the first, appear¬
ance of cardiac disturbance.

INDICATIONS FOR THERAPEUTIC ABORTION

299

Paroxysmal tachycardia will ordinarily respond to strophanthin
and even though the pulse may be extremely rapid and the feeling of
distress and palpitation pronounced, the danger is not great and no
interference with the pregnancy is justified. Von Orlowski lists
among the indications for therapeutic abortion the pressure of a large
aortic aneurysm, and also cases of advanced arteriosclerosis.

Winter claims that we cannot recognize as a prophylactic indication
for abortion, a history in a previous pregnancy of signs of cardiac de¬
compensation. In estimating the severity of the decompensation, he
says, less stress is to be placed upon such symptoms as dyspnea and
palpitation than upon the objective signs of edema, cyanosis and low¬
ered urinary output.

Among American cardiologists the majority would seem to favor a
more conservative attitude in the interruption of pregnancy for car¬
diac disease. Daly and Strouse make the just criticism that we have
heretofore tended to look upon these cases as pregnancies complicated
by heart disease rather than natients with cardiac lesions who have
become pregnant. In other words, the heart condition is the primary
condition and demands first consideration. These writers report the
end-results in the treatment of 352 pregnant women Avith organic
heart disease, only five of whom required interruption of pregnancy.
In nine patients in Avhom decompensation developed, it Avas found pos¬
sible to correct this and carry the pregnancy to term. Ninety-six per
cent recovered completely. Kellogg, Mackenzie and Smith also report
faArorable results from treatment so that therapeutic abortion rarely
proA^ed necessary. Campbell on the other hand believes that preg¬
nancy considerably increases cardiac damage and definitely shortens
the length of life. Both he and White belieA-e that every pregnant
Avoman suffering from mitral stenosis, fibrillation, or chronic myo¬
carditis should undergo therapeutic abortion and sterilization. In cases
of marked decompensation, hoAvever, time should be allowed for partial
recovery before proceeding with any operative measures to interrupt
the pregnancy.

As a result of comparing the life expectancy in cases of rheumatic
heart disease occurring in men, in nulliparous women, and in parous
women, Gilchrist and Murray-Lyon conclude that repeated childbear¬
ing (averaging over four children) accelerated the deaths of women
with such heart disease. Their analysis of 109 fatal cases indicated that
by escaping the burdens of a large family women could guard them¬
selves against the risk of congestWe heart failure until the age of
about 38 years, but usually died of embolus in the course of the fol¬
lowing twelve years. One, or at the most tAvo, children can be carried

300

ABORTION

to term without serious damage to the mother, but beyond this num¬
ber the risk of death is greatly increased.

Stander ’s study of 81 patients treated at the Woman's Clinic of
New York Hospital in 1932 showed that in every patient with a
definite history of decompensation, radical treatment should be
promptly employed. This consists of interruption of pregnancy with
sterilization.

The careful observations of Pardee upon the influence of pregnancy
on heart disease have helped our understanding of the subject. Since
we are less concerned with the location of the pathologic process than
with the strength and function of the heart muscle, Pardee has sug¬
gested certain tests of exercise to determine how much damage has
been done to the heart muscle. He divides his patients into four
classes :

Class I. Those who are able to perform ordinary and usual physical
activity without unusual fatigue, palpitation or dyspnea.

Class II A. Those who are able to perform the usual normal physical
activity but who have discomfort in so doing. Such a person would
have noticed an increase in shortness of breath after climbing stairs or
after walking against a wind or upgrade, or after such exertions as
house cleaning or lifting heavy articles. These patients would be said
by some to be “fairly well compensated.”

Class II B. Those who are unable to perform the more difficult fea¬
tures of ordinary physical activity without stopping on account of
fatigue, shortness of breath, or palpitation. Such activities would be
climbing two flights of stairs or walking at an ordinary rate for a half
mile. These patients might be called “somewhat decompensated.”

Class III. Those who are unable to perform the simplest physical
activity without fatigue or shortness of breath or palpitation. Such
a patient would be unable to walk 200 or 300 feet or to climb one
flight of stairs without resting, and would be unable to do any house¬
work. These might be said to be “much decompensated” or “def¬
initely decompensated. ’ 7

In drawing conclusions from these tests Pardee takes into consider¬
ation the geneial physical condition of the patient since some women
are under normal conditions more easily fatigued than others. This
is different from the shortness of breath experienced by the cardiac
case. Out of 112 cases in his original study at the New York Lying-In
Hospital, Pardee included two with congenital heart disease, 29 with
mitral insufficiency, 64 with mitral stenosis and 11 with aortic in¬
sufficiency. In addition to these, six patients entered the hospital

INDICATIONS FOR THERAPEUTIC ABORTION

301

with symptoms of serious heart decompensation ( Class III), five of
whom had a mitral stenosis and one an aortic insufficiency. Three out
of these six markedly decompensated cases died in spite of treatment.
Of the remainder, 75 cases were grouped as Class 1 , 20 as Class II A,
and 11 as Class II B. In the last named group there was also one death.
In general, Pardee believes that cases belonging to Class I and Class
II A may continue through pregnancy if kept under treatment. In
those belonging to Class II B and Class III the question of a therapeutic
abortion demands consideration and unless there is definite improve¬
ment under rest and treatment the pregnancy should be terminated as
soon as the patient ?s condition permits. Those who have shown evi¬
dence of dangerous decompensation in previous pregnancies should
be aborted at the first indication of heart failure.

In discussing Pardee’s recent paper on this subject presented at
the Cleveland session of the A. M. A. (1934), Hamilton takes excep¬
tion to the accuracy of the exercise test. He found it necessary to
recommend interruption of pregnancy in 54 out of 553 pregnant
women with cardiac disease at the Boston Lying-In Hospital. Forty-
five of these women had heart decompensation and nine had auricular
fibrillation or other conditions necessitating abortion. The majority
of these women should have been warned against pregnancy. Unfor¬
tunately many cardiologists fail to appreciate the inherent practical
difficulties attendant upon carrying out the very strict regimen neces¬
sary to keep such women from over-taxing their hearts. Too often
the doctor leaves orders and does not properly check up to see
whether they can be carried out. It is better to abort such women
than risk the chance of subsequent serious decompensation.

As to the time when such interruption should take place, there is
no question as to the advantage of early interference, preferably be¬
fore the sixteenth week. After that time the procedure itself becomes
more severe, according to Dame Mcllroy, and the possibility of saving
the life of the child must be weighed in the balance. The delay of
several weeks called for to make the exact diagnosis and fine-drawn
considerations recommended by some authors may remove the preg¬
nancy from that stage (before the second omitted period) where in¬
terruption is simplest and safest, into the third or fourth month,
where dangers of hemorrhage and infection are greatly increased.
Moreover we have in cardiac decompensation a condition that may
arise suddenly and require immediate intervention if the mother's life
is to be saved. Questions of anesthesia and the best methods of inter¬
vention in this later period will be discussed in the subsequent chapter
on Treatment.

302

ABORTION

Diseases of the Kidney. — Some kidney lesions have already been
discussed under the head of Toxemias. There still remain for consid¬
eration the following :

(1) Acute nephritis

(2) Chronic nephritis

(3) Pyelitis

(4) Tuberculosis of the kidney

(5) Pregnancy after nephrectomy

An acute nephritis following some infectious process during preg¬
nancy may produce hematuria and occasionally progress to a stage of
chronic nephritis, but does not, in the opinion of many obstetricians,
justify interruption of pregnancy since it will ordinarily subside
under proper treatment and with due care should not recur.

Strauss differentiates between those cases in which the kidney
disease arises during the pregnancy and those in which it preceded
the gestation. In the former group early albuminuria requires no
interruption and only if eclampsia or pre-eclamptic symptoms develop
early is interruption to be considered. In the latter group which in¬
clude chronic parenchymatous nephritis, abortion is usually indicated
owing to the threat of retinal hemorrhage and cardiac complications.
Herrick believes that when evidence of kidney disease arises early in
the piegnancy, the patient should be promptly aborted. In primary
nephritis with prolonged albuminuria, anemia and edema, the ab¬
sence of hypertension does not indicate that a therapeutic abortion
can be avoided. As an indication of renal sufficiency Mussey says
that a patient should have the ability to concentrate urine to 1,025
and dilute to 1,003 specific gravity.

Far more serious are the cases of chronic nephritis. If there is a
hydrothorax and hydropericardium, especially if there is nitrogen re¬
tention in the blood and beginning anuria, Winter says we should not
hesitate to end the pregnancy. He gives this as one of five indications,
the remaining four being: (1) Threatened or existing uremia, (2)
heart decompensation resulting from the kidney lesion, (3) early ap¬
pearance and progression of albuminuric retinitis, (4) amaurosis and
ablatio retinae.

The symptoms of impending uremia to be watched for are persist¬
ent vomiting, severe headaches and increasing torpidity. The eye
complications demand special consideration since we are here con¬
cerned not merely with possible danger to the life of the mother but
also with the conservation of her vision. Some ophthalmologists ad¬
vise interruption of pregnancy in all cases of retinitis albuminurica,
but Fink reports nine cases in which pregnancy went to term without

INDICATIONS FOR THERAPEUTIC ABORTION

303

permanent impairment of vision. Winter found it necessary to inter¬
rupt pregnancy only 6 times in 50 cases of chronic nephritis. In spite
of the fact that in many of these women there is permanent damage
to the kidney, lie does not believe that in a subsequent pregnancy we
are justified in doing an abortion for prophylactic reasons.

How far such conservative measures are to be followed will again
depend in some measure on the number of children and the social
economic conditions present. Sachs, cited by Winter, reports that
out of 48 pregnant women with chronic nephritis, only 21 gave birth
to a living child. When we consider this fetal mortality of 56 per
cent, together with a risk of premature detachment of the placenta
estimated by Winter at 12 per cent and the definite increased damage
of such a kidney in pregnancy, I believe prophylactic abortion should
be done more frequently.

The ultra-conservative attitude held by the European gynecologists
regarding abortion for chronic nephritis is not shared by Cary, AVat-
son, Stander and other Americans. If the woman is very anxious to
have the child and all risks are carefully explained, it is possible, as in
two recent cases in my own practice, to carry her through the preg¬
nancy safely. Such risks are, however, not justified in the vast ma¬
jority of cases. Hypertension is a danger sign that should usually
make abortion advisable. A woman whose kidney has been damaged by
chronic nephritis should not be compelled to go through her preg¬
nancy, unless she, knowing the chances, chooses to have her child.

According to B. P. AA7atson the high prenatal mortality in chronic
nephritis and chronic hypertension justifies more frequent interrup¬
tion of pregnancy. In a series of 322 cases of nephritic toxemia of all
degrees of severity the prematurity rate was 25 per cent, rising to 37
per cent in the severe cases. The total fetal mortality of the entire
series was 34 per cent, but where the toxemia was pronounced it was
69 per cent. ”A\re, therefore, consider,” he writes, “a pronounced
hypertension with or without albuminuria an indication for the in¬
duction of abortion.” Stander is equally positive in his recommenda¬
tion for termination of pregnancy in cases of chronic nephritis with
the prevention of any further pregnancy by contraception or sterili¬
zation.

Pyelitis of pregnancy is very common and will, of course, ordinarily
yield to simple medication, rest and diet. In some instances ureteral
catheterization and irrigation will prove necessary, at times even pro¬
longed drainage of the kidney pelvis for a week or two by means of
catheters. When in spite of these measures the high fever persists
and there is hematuria and rapid loss of strength, we must assume an

304

ABORTION

involvement of the kidney substance with nephrosis or perinephritic
abscess. In such cases interruption of pregnancy is indicated. If we
wait too long the condition may progress to a general septicemia.
This is fortunately a rare complication; Winter interrupted only once
in J 17 cases of pyelitis. Lutzenkirchen advises against delay if the
pyelitis has progressed to a pyelo -nephritis. The life of the child is
only rarely spared in these severe cases; hence there is less objection
to interruption, especially as it is far safer than operations on the
kidney during pregnancy.

Since abortion often sets in spontaneously in the more severe forms
of pyelitis and pyelo-nephritis, Goedecke does not find many cases that
require therapeutic abortion. The majority of patients will get well
with local measures and medicine but where serious damage to the
kidney or septicemia is threatened, an interruption of the pregnancy
should not be delayed, even if at a later date one kidney may require
removal.

Medical treatment and ureteral pelvic irrigations have greatly re¬
duced the number of cases requiring abortion in the opinion of Miku-
licz-Radecki. If, however, the kidney parenchyma is involved, the
outcome may be fatal unless pregnancy is interrupted. The indica¬
tions for therapeutic abortion are: (1) severe cases of pyelo-nephritis ,
especially if double-sided; (2) toxic pyelitis where pregnancy toxemia
is an important additional factor. He inclines toward more frequent
interruptions, since the child is lost in one-tliird of the cases anyway,
and there is considerable danger of permanent damage to the mother ’s
kidney s. In agreement with these views, Benthin advises prompter
interference since he lost two cases from excessive conservatism.

Tuberculosis of the kidney, if one-sided, primarily demands nephrec¬
tomy . Theiapeutic abortion is at times advisable in addition thereto.
If the tuberculosis is in both kidneys, we should interrupt at the
earliest, possible moment, since a delay to the later months will make

any treatment utterly valueless. Even so, the benefit will, of course,
be only temporary.

A previous nephrectomy may put the remaining kidney to some
added strain if pregnancy supervenes. This will rarely lead to con¬
ditions serious enough to require intervention. Certainly, in itself,

it rarely necessitates a therapeutic abortion, if the remaining kidney
is healthy.

Diseases of the Liver. — Acute yellow atrophy of the liver occurs in
about 30 per cent of the cases in association with a pregnancy. While
icterus has already been considered under the head of Toxemias, it

INDICATIONS FOR THERAPEUTIC ABORTION

305

should be borne in mind that every case occurring during pregnancy
demands careful consideration. If the icterus cannot be explained on
the basis of a cholecystitis, a calculus or intestinal disturbance, we
must, particularly in the early months, suspect a possible acute yel¬
low atrophy. The presence of a rapid pulse, fever, cerebral symptoms,
and hemorrhages in the skin and mucous membranes are diagnostic
of this condition, but at this stage the therapeutic abortion rarely
saves the patient ’s life. If done at the first signs of beginning toxemia
some help may be gained, but the diagnosis may prove faulty and
the procedure therefore unjustified. Liitzenkirchen also stresses the
severe toxic icterus appearing in the latter half of pregnancy, which
demands a termination of the pregnancy if other causes for the icterus
can be excluded.

Diseases of the Blood. — The physiological changes that occur in the
blood during pregnancy are relatively slight and of no serious sig¬
nificance. We find a slight increase of leucocytes, a thinning of the
blood, lowered color index and increase of fat content. Three condi¬
tions occur that may at times bring up the question of interruption of
the pregnancy :

(1) Pernicious Anemia

(2) Hemolysis of pregnancy

(3) Leukemia

Pernicious anemia may either precede the pregnancy and become
worse during the gestation, or it may arise during pregnancy. If the
patient is seen for the first time when she is pregnant, it may be im¬
possible to decide which form we are dealing with. The anemia that
develops as a result of the toxemia of pregnancy is the more serious,
and will in many instances justify interruption even though this pro¬
cedure may be of only temporary benefit. Frequent pregnancies in
close succession predispose to its development. The most vigorous
treatment with arsenic, blood transfusions and liver extract should be
at once undertaken, and if prompt benefit does not result, interrup¬
tion is generally advised. This will be more readily done if the preg¬
nancy is not yet far advanced. In the middle months the decision
may be difficult. Since the pernicious anemia is apt to become more
pronounced in the second half of pregnancy, it is wiser in doubtful
cases not to delay therapeutic intervention. Seitz stresses the pres¬
ence of megalocytes in the blood as an indication for interrupting
pregnancy. The recent development of treatment with liver extract
will doubtless materially reduce the number of cases of pernicious
anemia requiring abortion. Favorable results from liver treatment in

306

ABORTION

pregnancy have been noted by Schilling and others. In the extensive
review of Sachs, out of 22 women who survived the pregnancy by inter¬
ruption, 13 died subsequently.

Pregnancy hemolysis must be looked upon primarily as a manifesta¬
tion of toxemia. It may be hastened at times through giving such
drugs as quinine or veronal. There is both hemoglobinemia and hemo¬
globinuria. Indications for interruption have as yet not been decided
on, in view of the rarity of these cases.

Leukemia also is rarely associated with pregnancy. In fact no case
of chronic lymphatic leukemia in pregnant women is recorded, since
such women are invariably sterile. In the myelogenous type of the
disease, however, and in acute forms, it is occasionally found. Nau-
joks records but 30 cases altogether in literature. Kosmak’s two
cases ended fatally, one at three months’ gestation before abortion
could be done. Two cases I observed in the service of the Washing¬
ton University Department of Obstetrics are especially illuminating.
The first was one of acute leukemia that ran a rapid course terminat¬
ing in spontaneous expulsion of a six months’ macerated fetus, with
the death of the mother eleven days later. Several transfusions were
of no avail in this patient. This typifies the usual course of the dis¬
ease. Even relatively early abortion will be of little help in acute
leukemia but the majority of obstetricians feel it is indicated in these
cases.

The other case observed in our service for a long period was one of
chronic myelogenous leukemia, diagnosed and vigorously treated with
x-ray before the pregnancy ensued. Great care had been taken to
protect the ovaries from radiation and this accounts for the fact that
a pregnancy was possible and that when it proceeded to termination
a healthy child was born. This child is now over two years of age
and shows every evidence of being entirely normal. In this patient
the unusually large liver and spleen, reaching down to the navel, were
no serious complication to the development of the pregnancy, and
labor set in practically at term. The mother died of her leukemia
about nine months after the birth of her child. Whether such conser¬
vation is always justified is open to question. In Levy-Lenz’s book
interruption is advised, whereas Winter does not favor it. Naujoks
believes that in the interest of the mother more active measures for
interrupting pregnancy are justified. In our own case the amenor¬
rhea was interpreted as due to the previous x-ray treatment and the
case was not referred to the obstetrician until pregnancy had advanced

INDICATIONS FOR THERAPEUTIC ABORTION

307

to the fifth month. With a relatively favorable blood picture at this
time it was decided to let the pregnancy proceed.

Twenty-six cases from literature in which leukemia was the indi¬
cation for interrupting pregnancy are analyzed by Hof stein. Ten of
these were acute and sixteen were chronic leukemias. In one patient
with chronic myeloid leukemia there was a rapid increase of leuco¬
cytes at the onset of pregnancy and after artificial abortion at the
second month there was marked improvement. In acnte leukemia
there is so little prospect of gain by the abortion that it hardly ever
is justified.

Skin Diseases and Syphilis. — Skin lesions resulting from the toxins
of pregnancy may take the form of a pruritus, herpes, erythema,
urticaria or impetigo. While these conditions produce pronounced
discomfort to the patient, they do not indicate an interruption except
in the severe form of an impetigo herpetiformis. In such an impetigo
there are large pustules over the entire body associated with fever.
Hebra saw five cases, four of which ended fatally. The disease is
more common in the second half of pregnancy and the interruption
of pregnancy is not of great value in lessening the mortality. The
majority, however, favor adopting such measures early in the disease.
Buschke and Curth advise abortion in severe cases of herpes gesta-
tionis. In pemphigus, however, it is justified in their opinion only when
the patient is definitely growing worse.

Syphilis as an indication for therapeutic abortion has been advised
by a few persons in those cases that resist treatment. This has not,
however, been generally accepted. Sprecher believes that modern
methods of treating syphilis make this indication unnecessary. On
the other hand Buschke and Gumpert analyze the serious effect of
syphilis upon the offspring and the difficulty of carrying out any ef¬
fective treatment. They stress the high incidence of imbecility (13-25
per cent) among children with congenital lues. They, therefore, be¬
lieve that, if a proper course of intensive treatment is impossible, in
cases of familial syphilis of the nervous system, a therapeutic abor¬
tion should be given serious consideration.

(6) Endocrine Disturbances

The pronounced changes occurring in the endocrine system as a
result of pregnancy are best evidenced by the tremendous outpouring
of pituitary secretions demonstrated in the Aschheim-Zondek test. It
is not surprising, therefore, that during pregnancy the glands of in-

308

ABORTION

ternal secretion may undergo serious alterations and result in patho¬
logical conditions imperiling the life of the mother. The more im¬
portant of these diseases of metabolism and the endocrine organs are:

(1) Diabetes

(2) Osteomalacia

(3) Tetany

(4) Hyperthyroidism and hypothyroidism

(5) Addison’s disease

Diabetes in relation to pregnancy has been greatly influenced by
the discovery of insulin. Before the days of insulin, diabetic women
were almost invariably sterile as a result of general debility, atrophy
of the ovaries and alteration of sexual desire. After the employment
of insulin, women with diabetes who have been sterile will readily
conceive. Thus in one way the problem has become more important
than heretofore. Furthermore the results of treatment with diet and
insulin have been so brilliant, even in cases of diabetic coma, that we
no longer need to condemn such women to a childless marriage. Our
advice will, of course, be largely governed by the severity of the
case and its response to treatment, since there is no question that the
mother’s diabetes is as a rule unfavorably influenced by the preg¬
nancy and in addition thereto we must face a greatly increased fetal
mortality with a not inconsiderable risk of deformities.

Occasionally the diabetes makes its first appearance during the
pregnancy and in these cases, as Naujoks points out, the prognosis is
usually very good. An increased risk of spontaneous abortion is also
present in these diabetic women. Umber and Rosenberg, who believe
that it is possible with proper treatment to allow every diabetic to
undertake a pregnancy without serious risk to her life, nevertheless
qualify this by demanding an abortion: (1) if we are dealing with a
severe diabetes associated with pronounced acidosis; (2) if the preg¬
nancy is definitely leading to a lowered tolerance and increased con¬
sumption of insulin; (3) if external conditions prevent a consistent
complete treatment with diet and insulin throughout the pregnancy.

Peckham followed the course of seventeen pregnancies in twelve
diabetic women. He concludes that the disease may become exag¬
gerated in the first two-thirds of pregnancy but improves in the last
three months. Under careful supervision the average diabetic woman
should be able to go through a pregnancy with reasonable safety.

Liitzenkirchen stresses as an indication for abortion a severe
acidosis in association with ketonuria, that resists diet and insulin.
She also considers hyperemesis and toxic kidney complications as symp-

INDICATIONS FOR THERAPEUTIC ABORTION

309

toms of danger. Cases in which the diabetes is more pronounced at
the menstrual period are more likely to require intervention in preg¬
nancy. Naujoks as a result of an inquiry among internists concludes
that therapeutic abortion is indicated only after failure to correct the
diabetes by insulin treatment regardless of its apparent severity, and
in those cases where there has been an exacerbation of the diabetes in
pregnancy and it is impossible for external reasons (social conditions,
distance, etc.) to carry out consistent treatment. Ehrenfest believes
that with insulin the dangers for mother and child are eliminated.
The late Nellis Foster, however, considered that diabetes should be
considered a eugenic indication for abortion, since the child was likely
to be congenitally diabetic.

Osteomalacia due to liypof unction of the ovaries is an increasingly
rare disease. It is controllable by internal medication with phos¬
phorus and calcium or in more severe cases by removal of the ovaries.
The disease often begins during pregnancy and as a rule develops
more rapidly as a result of gestation. The outcome is fatal if not
treated, but treatment by ovariectomy, which can be performed dur¬
ing pregnancy without risk of abortion, is successful in 87 per cent
of the cases according to Winter. Only in younger individuals who
resist treatment with medication can abortion be advised in order to
avoid the necessity of sterilization at this age. Such an indication
will only rarely arise. Since living conditions and diet play such an
important part in the cure of this malady, abortion may be preferable
in young primiparae to give them time to eradicate the disease with¬
out operation and permit in later years the normal birth of such chil¬
dren as are desired.

Tetany may prove fatal to the expectant mother through muscular
cramps involving the larynx and pharynx. It results from damage
by the toxins of pregnancy on the parathyroids. There is normally
an increased nervous irritability during pregnancy, so that milder
manifestations, so-called subtetanic symptoms, are not rare (accord¬
ing to Seitz, 10 per cent). True tetany is rare but may be very severe
and whenever the muscles of respiration are involved, demands thera¬
peutic abortion. The results of such treatment are usually very satis¬
factory. In Levy-Lenz’s monograph, the dangers of a previous thy¬
roidectomy, or depleting chronic infections when associated with
tetany, are stressed and abortion is advised under such conditions.
Where tetany has occurred in a previous pregnancy, abortion should be
induced at the first appearance of symptoms pointing to a recurrence
of the disease. Tetany occurring during pregnancy has a mortality

310

ABORTION

of 7 per cent according to Seitz, who reported 83 cases. Where preg¬
nancy is interrupted in the later months results are less favorable
than if done early.

Thyroid disturbances of a milder type are quite common in preg¬
nancy. There may be either an increased or a lowered activity of this
gland. An increase in size of the thyroid is quite commonly observed
in pregnancy but is of no significance except where there are definite
symptoms of toxicity pointing to Graves ’ disease. Rubs amen, Beck
and Gross saw only 13 cases out of 700 enlarged thyroids in preg¬
nancy in which the size of the tumor caused embarrassing pressure
symptoms. Strumectomy will give such patients complete relief and
does not ordinarily interrupt the pregnancy. They reported 6 per
cent of spontaneous abortions.

Graves' disease when complicated by a pregnancy may lead to the
development of a thyroid heart, and it is such cardiac conditions that
necessitate oftentimes more radical measures than rest and LugoFs
solution. If the tachycardia is attended by symptoms of heart de¬
compensation we must choose between partial strumectomy or inter¬
ruption of the pregnancy to prevent more serious damage. The de¬
cision between these two is often difficult, but strumectomy is usually
preferable, unless the patient’s condition militates against operative
measures, or unless there is pronounced hyperemesis, chronic nephritis
or cardiac decompensation. Except in the presence of enlargement of
the thymus gland, therapeutic abortion will usually give prompt
relief in these cases.

Winter reports 11 successful cases in 15 abortions. Occasionally
the failure to get a satisfactory result with surgical resection of the
thyroid will necessitate a later interruption of the pregnancy. It is
for this reason that Liitzenkirchen feels that in doubtful cases it is
safer to interrupt the pregnancy at once.

Daly and Strouse state that abortion is rarely indicated for hyper¬
thyroidism ■, since it may diminish the thyroid toxicity but will rarely
produce a true remission. In contradistinction to this viewpoint is
the experience of Seitz, who found that 60 per cent of 112 treated
cases of toxic thyroid required abortion. On the whole, however,
opinion favors the active treatment of the thyroid disease rather than
any interruption of pregnancy.

Addison’s disease is usually due to tuberculosis of the adrenals. It
is rendered worse by pregnancy. Frequently there is associated with
it a tuberculosis of other organs. Too few cases have been observed
to justify a positive opinion but a priori it would seem that a thera¬
peutic abortion is advisable to check the spread of the disease.

INDICATIONS FOR THERAPEUTIC ABORTION

311

(7) Diseases of the Nervous System

Diseases of the nervous system as they are influenced by the preg¬
nant state may at times give rise to the necessity of a therapeutic
abortion. So difficult, however, is it to judge wisely as to the indica¬
tions, that in every instance a psychiatrist or neurologist should be
asked in consultation and sufficient time given to arrive at a satis¬
factory diagnosis and prognosis.

Cerebral neuroses include neurasthenia, hysteria and epilepsy. The
first two of these conditions should never justify abortion, but epilepsy
will at times become so pronounced, leading to the condition known as
“ status epilepticus, ” that the pregnancy must be interrupted to save
the life of the mother. Haupt calls attention to the fact that over
one-half of 19 cases of “ status epilepticus” with pregnancy ended
fatally. In one case the patient's condition was so serious that no
operative measures could be employed. A lumbar puncture, removing
40 c.c. of liquor and injecting 20 c.c. of air, caused cessation of at¬
tacks. Later an abortion and sterilization was done. Hofmann ad¬
vises that in every case of epilepsy the conditions and number of at¬
tacks be closely watched so that the interruption of pregnancy is not
unduly delayed when conditions are rapidly growing worse. About
40 to 50 per cent of epilepsies are unfavorably affected by pregnancy.
Occasionally, however, there is a definite improvement at such periods.

Of the organic diseases brain tumor may on rare occasions present a
problem. Believing that they show no increase in size in pregnancy,
Winter does not agree with Plaszek that pregnancy should be inter¬
rupted in these cases. Acute encephalitis may arise upon a toxic basis
and for that reason a therapeutic abortion is indicated. Bland and
Goldstein call attention to the frequency with which such an acute
encephalitis is followed by paralysis agitans. If the encephalitis oc¬
curs during pregnancy, this complication occurs three times as often
as in the non-pregnant woman. Encephalitis lethargica is so little in¬
fluenced by the pregnant state, that there is rarely an indication for
interrupting the gestation.

Spinal diseases complicated by pregnancy are: (1) tabes dorsalis;
(2) multiple sclerosis; (3) myelitis.

Tabes is not unfavorably influenced by gestation, except in a few
asthenic individuals. Winter interrupted the pregnancy in two young
women with hereditary tabes dorsalis in whom marked improvement
had occurred in the interval between the pregnancies. For eugenic
reasons, however, abortion must be advised in most cases of tabes or
other forms of cerebro-spinal syphilis.

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ABORTION

Multiple sclerosis is very definitely influenced by pregnancy, and
occasionally begins at this time. Symptoms are exacerbated with the
pregnancy and become more pronounced with each child. Marked
improvement is noted after the conclusion of the pregnancy. It,
therefore, is a definite indication for therapeutic abortion whenever
there is an exacerbation in the pregnancy and, according to Orze-
chowski, whenever in preceding pregnancies there has been an in¬
crease in symptoms.

Myelitis is in the opinion of most neurologists a toxic effect of the
pregnancy. It usually arises during pregnancy, becomes worse dur¬
ing that period and may recur in later pregnancies. Hence thera¬
peutic abortion is indicated, even though in some cases there is no
improvement following this procedure.

Of the peripheral nerve lesions influenced by pregnancy we must
mention localized neuritis and polyneuritis. Localized neuritis is of
little moment unless such nerves are affected as the vagus, or in the case
of optic neuritis leading to loss of vision.

Polyneuritis is a form of pregnancy toxemia resulting as a rule
from prolonged or severe hyperemesis. From studies made thus far,
it seems probable that the nerve lesions are due to absence of vita¬
mins, especially vitamin B. This condition of avitamosis produces
Korsakow’s syndrome (hyperemesis, polyneuritis, psychosis). In the
experience of 0. Schwarz at the St. Louis Maternity Hospital this is
an indication for prompt emptying of the uterus. If done in time the
abortion will stop the progress of the polyneuritis and tend to a gradual
recovery of function. With this complication mortality is high, ac¬
cording to Hoesslin who reports one-fifth of 46 cases dead. Cases of
rapidly ascending Landry's paralysis present a somewhat similar pic¬
ture and according to Winter’s advice should be aborted.

According to Buchler it is beyond dispute that spinal and cerebral
tumors, syringomyelia, progressive spinal muscular atrophies, heredi¬
tary chorea, lateral sclerosis, and severe forms of epidemic encepha¬
litis form absolute indications for abortion. In doubtful cases Buch¬
ler holds that social and eugenic considerations may be allowed to
influence the decision.

Psychosis. — It is not surprising that a pregnancy that is for some
reason undesired and seriously complicates the life, the occupation or
social standing of the individual, will result in a pronounced psychic
upset, especially in individuals whose mental balance has previously
been below par. Figures are lacking as to the frequency of suicides
resulting fiom such states of mental depression, but it is certainly an
important factor in suicides among women. Hence the physician

INDICATIONS FOR THERAPEUTIC ABORTION

313

must face the difficult decision of therapeutic abortion in these cases.
On the one hand, the woman may threaten suicide for the purpose of
obtaining- her end, an abortion ; and on the other, we may have a true
psychosis in which the woman is no longer responsible for her actions.
Interning such a patient in a sanatorium may at times clear up the
diagnosis and result in definite improvement. Singer also stresses as
a psychic factor in these women the fear of the sufferings and dangers
of labor. Where a state of nervous exhaustion results from these
continued worries, an abortion may in rare instances be justified.
Mingazzini is somewhat lax in his indications for abortion. He be¬
lieves that in multiparae with pronounced nervous symptoms such as
pressure on top of the head, eye symptoms, weariness, sleeplessness
and irritability, interruption of pregnancy for the sake of the mother
is justified. In every such case the previous history and the family
inheritance of the individual must, be given special consideration.
Fraenkel calls attention to the fact that the abortion itself may result
in new psychoses, and that therefore we are jumping from the frying-
pan into the fire by interrupting the pregnancy.

H. W. Maier calls attention to the fact that in the past fifteen years
in Zurich there has been a marked increase in the number of psychi¬
atric patients referred for therapeutic abortion. In the years from
1929 to 1931 alone in the city of Zurich with a population of 400,000
inhabitants, there were 718 therapeutic abortions for psychiatric rea¬
sons, in 481 of which this procedure was combined with sterilization.
In 529 other patients interruption of pregnancy was considered but
refused because of insufficient indications. The indications were, on
the one hand, cases of involuntary pregnancy due to rape, idiocy or
under-age (less than 15 years) ; and on the other hand, medical con¬
ditions affecting the somatic and psychic constitution of the individual.

Many writers, including B itchier and Cheney, believe that there is
no individual disorder that is in itself an absolute indication for abor¬
tion, but rather that each case must be judged for itself. Eugenic
factors, Maier says, are not decisive but must be given due weight.
Where the psychic factors are apt to recur in succeeding pregnancies,
sterilization should always accompany the abortion.

The two psychoses that need consideration in this chapter on thera¬
peutic abortion are dementia praecox and manic depressive insanity.
In dementia praecox we have frequently a tendency to increasing im¬
becility during pregnancy. A single period of exacerbation of symp¬
toms does not justify interruption but if we have a history of such
an exacerbation occurring in previous gestations, then we are justi¬
fied at the first indication of the advance of the disease in interrupt¬

ing a new pregnancy.

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ABORTION

Strohmeyer states that dementia praecox has a specially bad prog¬
nosis if the onset is during pregnancy, or if there has been an exacer¬
bation of symptoms at this time. In 92 out of 107 cases of dementia
praecox Herzer found that the disease began during pregnancy, puer-
perium or lactation. Lienau and Saenger found that therapeutic
abortion and sterilization had a definitely favorable effect on the
psychosis. Most psychiatrists would deny any such improvement as
a result of abortion but would concur in the idea that for eugenic and
social reasons patients with this disease should be aborted and sterilized.

In manic depressive states, while the pregnancy has no direct harm¬
ful effect upon the psychosis and while the child may be perfectly
normal, practical considerations will usually make an interruption
advisable. The inability of the woman to care for her child, not to
mention complications in labor and occasional attempts at suicide,
make it preferable to induce an abortion rather than to permit the
birth of a child under such distressing circumstances. Sterilization
should, of course, accompany such a therapeutic intervention.

(8) Diseases of Special Organs (Eye and Ear)

Eye Diseases.— Some of the eye conditions requiring therapeutic
abortion have already been mentioned, under Kidney Diseases. Cer¬
tain toxemias produce their most serious lesions in the eye. We may
have retinitis, optic neuritis, separation of the retina and less often
such milder conditions as keratoconus. Functional disturbances in
the form of hemianopsia and narrowing of the visual field may at
times arise during pregnancy. Winter stresses the fact that all these
eye conditions do not endanger the mother’s life, nor are they often
double-sided. Even when only one eye has been seriously affected,
there is a considerable risk of lesions of a similar nature appearing
in the other eye sooner or later. Winter, therefore, advises that where
the vision of one eye is seriously threatened by a condition resulting
from the pregnancy, we should proceed with therapeutic abortion.
The occurrence of hemorrhagic retinitis in pernicious vomiting of
pregnancy is in Stander’s opinion an indication for therapeutic abor¬
tion. The character of changes noted in two such cases makes it
probable that the eye lesion is caused by a change in the permeability
of the capillary walls. Routine repeated examination of the eyegrounds
should be made in all cases of hyperemesis.

According to Szwarc, we can distinguish two groups: diseases
starting in pregnancy and those aggravated by pregnancy. Most im¬
portant in the first group is the retinitis albuminuria appearing as an
indication of pregnancy toxemia, pictured in Fig. 117. Winter, Szwarc,
Krieger and others recommend immediate evacuation of the uterus
when this condition appears.

INDICATIONS FOR THERAPEUTIC ABORTION

315

Whenever eye changes indicate a moderately advanced stage of
pregnancy toxemia, a careful study of the eyegrounds may, according
to Wagener, be of great prognostic importance. Retinal hemorrhage
and optic neuritis indicate severe toxemia and require prompt abor¬
tion, both because of the renal condition and the danger of blindness.
Bedell in discussing Wagener 's recent contribution to this subject em¬
phasizes the early recognition of hard and rigid arterioles by the
ophthalmoscope so that by early abortion more serious damage may

Fig. 117. — Albuminuric retinitis as an index of severe toxemia in nephritis. Note
the speckled appearance of the retinal membrane and the rigid arterioles. The blood
vessel changes are noted relatively early in the toxemia and almost always demand
prompt therapeutic abortion. (Clarke: Fundus of the Human Eye.)

be prevented. Menge, who is ultra-conservative as to therapeutic
abortion, would limit interference until after the period of viability
and then induce labor.

Concerning separation of the retina ( ablatio retinae) there is gen¬
eral agreement that immediate therapeutic abortion is indicated in
practically every case. It is usually the sequel to a toxic retinitis of

316

ABORTION

pregnancy but may at times appear in otherwise healthy pregnant
women. The only chance to avoid blindness is the interruption of the
pregnancy. In a considerable number of cases when this was done
within two weeks of the time of the retinal separation, the retinal
membrane returned again to its former position without material
damage to vision. Cases are recorded by Delpozzo, Soli and Vorderame
in which in two successive pregnancies, vision was lost in one eye where
no interruption was done and saved in the other eye following thera¬
peutic abortion. In keratoconus, abortion is advised by Szwarc only if
the second pregnancy definitely causes the condition to grow worse.

In the group of pre-existing disease, Szwarc includes as justifying
abortion tabetic optic atrophy , tuberculosis of the ciliary body , optic
neuritis on a diabetic basis, and retinitis. Winter calls attention to the
varying intensity of the optic neuritis. While usually one-sided, the
disease may spread rapidly during pregnancy. In view of the relief
given by the termination of the pregnancy, abortion at an early stage
is indicated in every case of even moderate severity. Cases are recorded
of what Krieger terms “pernicious myopia” in which during each preg¬
nancy the vision becomes markedly poorer. This, together with the
danger of retinal loosening in such cases, justifies ending the gestation.
Bathe speaks of the danger of retinal bleeding in these cases of myopia.

Ear Diseases. — The risk of loss of hearing is not as great as that of
blindness. Yet there is one condition, generally becoming worse in
pregnancy, that requires consideration. Otosclerosis is in 88 per cent
of cases double-sided, a chronic inflammatory process, leading to deaf¬
ness. While no one denies that the disease will progressively grow
worse, many otologists recommend interruption of pregnancy to delay
the advance of the disease.

(9) Other Unclassified Diseases

A few other unclassified conditions have from time to time been
brought forward as an indication for therapeutic abortion. In caries
of the bone , according to Fekete, the difficulties of calcium metabolism
during pregnancy have raised the question as to interference. Our in¬
formation as to the harmful effects of pregnancy in these cases is too
meagre, I think, to justify intervention. A case of severe fracture of
the vertebral column in a three months’ pregnant woman requiring the
prolonged use of rigid and constricting apparatus was recently ob¬
served by Ehrenfest and myself and the patient allowed to go to
term without any serious complication and with perfect union of the
vertebra. Varicose veins may at times completely incapacitate the
pregnant mother, but the fact that absolute rest in bed gives relief in

INDICATIONS FOR THERAPEUTIC ABORTION

317

most cases makes abortion rarely justified. An associated phlebitis will,
however, at times necessitate therapeutic interruption. Hernias may
become more pronounced during* pregnancy but the treatment must con¬
sist in replacement or herniotomy, and not in uterine evacuation. The
same criticism applies to appendicitis and cholecystitis.

In a patient having Pott’s disease Tassovatz found that the old ver¬
tebral lesions were softened with the onset of pregnancy and hence
proceeded with a therapeutic abortion to prevent lighting up new tuber¬
cular deposits. Vertebral deformity in which pregnancy would cause
increased pressure on the spinal cord and serious disability was the in¬
dication that prompted Eisenreich to proceed with abortion in two of
his cases. Other rare indications for interruption reported by him in¬
cluded two cases of breast cancer , operated upon a year and a half be¬
fore the onset of the gestation, in which he feared a greater tendency
to recurrence if the pregnancy were to continue.

(10) Rape

The indication for therapeutic abortion in cases of rape will, of
course, depend to a considerable degree upon the evidence produced
by the woman that such an assault has actually been committed. That
the physician is not always in a position to gather and weigh such
evidence is manifest ; hence he will do better to be guided in doubtful
cases by the decisions of the court. If rape has been committed, there
is general agreement that an emptying of the uterus is justified, if
pregnancy arises as a result thereof. In the cases of girls pregnant
under sixteen years of age the laws of Czechoslovakia permit abortion
since they are considered to be irresponsible before this age. While
our own laws and those of other countries do not as a rule recognize
rape or extreme youth as indications for abortion, we as physicians,
knowing the harmful mental or physical effects produced by a preg¬
nancy in such cases, should seek to justify an abortion for medical
reasons. If the abortion is done openly, there is little doubt that the
courts would uphold such a decision.

(11) Eugenic Indications

On the borderline between medical science and sociology lies the
field of eugenics, concerning which much has been written and yet so
relatively little is known. Each decade has, however, added material
and bit by bit we can begin to distinguish between those conditions
that are definitely heritable, those that play a certain part in heredi¬
tary stigma, and finally those that have been overestimated in the past

318

ABORTION

and are really of little consequence. Let us suggest a spirit of sane skep¬
ticism in arriving at our decision. In many individuals, we might
urgently advise against a pregnancy, or even under certain circum¬
stances be willing to proceed with a sterilizing operation. Yet, if
faced with a pregnancy actually established, we should be compelled
to balance carefully the certainty or weighty likelihood that the dis¬
ease or condition would be inherited. No doubt too many idiots and
imbeciles are being born in the world but the differentiation as to
likelihood of inheritance of such a taint must be given due consideration.

Only two general diseases of consequence can be directly trans¬
mitted from mother to child : tuberculosis, very rarely, and to a
limited degree, syphilis. Both conditions can be usually controlled
by proper treatment and therefore do not present a eugenic indication.

It is primarily with those conditions affecting the germ-plasma in
which a taint or abnormality is definitely transmitted from generation
to generation, that we are concerned. Max Hirsch, who lias made pro¬
longed studies of these problems, believes that we should extend our
indications, including not merely danger to the mother but also
danger to the child and the coming generations. He agrees with
Nietzsche, who was more concerned with the “Kinderland” than with
the “Vaterland. ” Unfortunately the marriage rate and birth-rate
among the feebleminded is alarmingly high. Rentoul in 1901 in Eng¬
land found 18,900 married out of 60,721 feebleminded women; and
46,800 married among 117,274 insane women. The fertility of such
women is illustrated by the reports from Rostock, giving 1,490 chil¬
dren in 234 mothers (6.4 children per mother).

Naturally no one would recommend therapeutic abortion for such
minor deformities, even though definitely inherited, as polydactylism,
clubfoot, tibial defect or color blindness. On the other hand if the
inherited taint interferes with mental development (idiocy, imbecility,
feeblemindedness) or if it leads to congenital blindness (amaurosis,
microphthalmus, aniridia) we must give the matter very serious con¬
sideration. Such cases will, of course, be quite rare and it is well,
wherever possible, to consult with some specialist in genetics before
reaching conclusions. Hirsch would recommend abortion in cases of
retinitis 'pigmentosa, amaurotic idiocy, dementia praecox, manic-depres¬
sive insanity, Huntington’s chorea and genuine epilepsy . Hirsch would
rather abort than sterilize such women. Vonnegut, I think rightly, in¬
sists upon sterilization with abortion; for if it is serious enough to
justify the latter, the former is also indicated. Hirsch would have
the laws widened in scope to include eugenic abortion by the word-

INDICATIONS FOR THERAPEUTIC ABORTION

319

ing : ‘ ‘ The interruption of pregnancy is legal, provided it is done by
a physician and justified by the observations of science.’ ’

Yonnegut, however, maintains that this is unnecessary and might lead
to abuses. He contends that in the rare instances where such abortion
is advisable, medical ethics would justify the procedure regardless of
the absence of any legal right, just as for years therapeutic abortion
for medical diseases was done without legal justification. This posi¬
tion is illogical. If it is morally and scientifically right to abort, it
should be made legally right also.

Winter mentions the following conditions which show a definite
hereditary tendency : (1) Psychoses such as dementia praecox, idiocy,
and severe fatal epilepsy. (2) Results of alcoholism: for instance,
idiocy, psychoses, epilepsy. (3) Nervous diseases such as hereditary
ataxia, spastic spinal paralysis, Huntington’s chorea, myotonia con¬
genita. (4) Eye diseases such as retinitis pigmentosa, optic neuritis,
glioma leading to blindness.

An interesting discussion of the eugenic indications for therapeutic
abortion and sterilization recently took place in German medical cir¬
cles. Reading between the lines the influence of Nazi doctrine was
manifest. The sterilization of the unfit was generally accepted, al¬
though one Catholic physician, Niedermeyer, argued that sterilization
was ethically just as wrong as interrupting pregnancy. Seitz and
Naujoks favored interruption of pregnancy for eugenic reasons as
well as sterilization and would combine the two procedures. Eugenic
control in psychiatric patients should in the opinion of Bumke never
justify birth control measures, since the normal would make use of
such devices as well as the abnormal, thus increasing the danger of
the “birth strike” which threatens the extermination of the Teuton
Aryan race. Riidin feels that sterilization of the unfit is better than
inducing abortion but favors eugenic indications in cases of pregnancy
for the betterment of the race.

If it could be proved that such diseases were always and positively
inherited, there could be little argument against therapeutic abortion
to prevent the birth of such unfortunates. Much study is however
still required before we can positively take such a stand. We should
be more inclined to interference on subsequent pregnancies if one or
more children had already been born with such an inherited taint.
Hessberg mentions such a case. The parents were both blind early
in life with microphthalmus and amaurosis. Two children had been
born blind with almost total aniridia and nystagmus and the mother
was again four-and-a-half months pregnant. In spite of the fact that
therapeutic abortion was advised, the father refused and the third

320

ABORTION

child was later born with the same eye defect, totally blind. On the
other hand Fleisclimann discusses the case of a woman with congenital
cataract of both eyes, who was already in the fifth month of her preg-
nancy. Although fifteen out of thirty-four members of this family
had either cataract or amblyopia, pregnancy was not interrupted be¬
cause of the risk of interference at this late stage. As chance would
have it, a healthy girl was born at term. The mother, however, con¬
sented to sterilization five months later.

The Eugenics Society last year produced a volume “The Chances
of Morbid Inheritance,’7 in the form of a symposium by specialists,
designed to give physicians a basis for judgment in these matters.
Genetic Principles, Nervous Disorders, Epilepsy, Mental Disorders,
Diseases of the Eye and Ear, Allergic Diseases, Cretinism, Diabetes,
Tuberculosis, Analysis of Pedigree, etc., are all discussed. Before de¬
termining the question of a therapeutic abortion for eugenic reasons,
it would be well to consult the evidence presented by these writers.

Granting fully the difficulties of proof in these cases of inherited
disease, I would incline to favor an extension of the indications foi
therapeutic interruption but would insist upon simultaneous steriliza¬
tion of such a tainted individual, if after consultation such an abor¬
tion seemed necessary.

(12) Social-Economic Indications

The moment we proceed to a consideration of therapeutic abortion
for social or economic reasons, we tread upon dangerous ground, for
we are getting away from the purely medical aspects of the case and
our information comes from sources the reliability of which may be open
to question. The spread of social service in association with hospitals
and dispensaries throughout the country lias, however, materially im¬
proved the accuracy of information obtained regarding the living
conditions of our patients. This has led us all to appreciate the bear¬
ing of these factors upon the physical well being of the entire family.
To proceed with a therapeutic abortion merely because there is al¬
ready a large family of children may be permissible in Bussia, but
is not as yet accepted as a wise course by the rest of the world. We
should not, however, close our eyes to the direct effect of such a
burden of children upon an already impoverished and underfed family.
It is foolish to measure every thing by one standard. Burdens that
are safely carried by one woman may readily undermine the health
of another.

INDICATIONS FOR THERAPEUTIC ABORTION

321

If prevention of disease is wiser than its cure, then we cannot en¬
tirely set aside a consideration of sncli social-economic indications.
It has already been stressed that in many cases of tuberculosis and
heart disease a report on the social conditions present materially in¬
fluences our decision whether or not to interrupt. I am inclined to
believe that abortion may also be justified in patients showing asthenia,
loss of weight, and physical depletion, especially if there are several
children, and the mother has heavy household duties, and lacks re¬
sources properly to care for those children already born.

Some conservatives such as Winter, believe that therapeutic abor¬
tion for social-economic reasons would let down the bars to all man¬
ner of abuse. I cannot agree with this. We should not hesitate to
proceed with measures, simply because an unscrupulous person may
take advantage of them for his own gain. Even now, as we all know,
medical indications are often loosely established and abortion done
merely for the convenience of the patient and the financial gain of
the physician. Would it not be better if the indications were extended
to include these depleted pluriparous women, particularly if we insist
that such an abortion could only be done in a registered hospital
after a careful survey of the facts and after consultation by two or
more physicians? For the present we must reluctantly agree that
physicians are not permitted to perform an abortion until the health
of the mother has already been impaired. As physicians, we are, how¬
ever, justified and obligated in trying to persuade our fellow-citizens
to consider this problem from the broader aspects of preventive medi¬
cine, and ask them to take such steps, legal and otherwise, as will
make it possible for the conscientious physician to do an abortion
under such circumstances to preserve the health of the mother and the
integrity and well being of the family.

CHAPTER XX

METHODS AND TECHNIQUE OF
THERAPEUTIC ABORTION

T TAVINGr DETERMINED in accordance witli the principles of the
* * preceding” chapter the necessity of interruption, we are faced
with the decision, by no means simple, of the best method of emptying
the uterus in the particular case. There is no one method that is
superior to the others, rather must we study the various factors in
each case and select the one that is most suitable for that particular
condition. This will depend upon the underlying disease that calls
for the abortion, the stage of the pregnancy, previous parity, neces¬
sity of simultaneous sterilization operation, surroundings under which
the abortion is to be done, and skill and experience of the accoucheur.
Before proceeding to a discussion of the selection of the preferable
method, let us analyze the various methods available. These may
broadly be divided into the non-surgical and the surgical methods.

Non-Surgical Methods

Drugs. — Of the drugs that stimulate uterine contractions few are
sufficiently powerful to induce emptying of the uterus, unless through
fetal death, or other factors, the uterus has been rendered more
sensitive to their effect. Quinine and pituitary extract have thus
been occasionally employed with success in pregnancies between
the fourth and sixth month. Schimmel claims that in pregnancies
later than the second month ergot if given in large quantities will
occasionally bring on expulsion of the ovisac. He gives a potent
preparation of ergot, gynergen, 2 c.c. hypodermically three times a
day for three days, a total of 18 c.c. This amount would seem to be
not devoid of danger of ergot necrosis and hence cannot be recom¬
mended. Turolt reports complete failure in inducing abortion with
gynergen. Winter suggests the use of ergot in combination with
mechanical stimulation (massage or heat), but acknowledges that it
is rarely successful.

Hormones. — Interesting and suggestive is the recent experimental
work of Margaret Smith at Johns Hopkins. She found in working
with rats that abortion could be produced with injections of large
amounts of follicular extract obtained by the Allen-Doisy method,

322

TECHNIQUE OF THERAPEUTIC ABORTION

323

given in the first five days of pregnancy. Larger amounts were re¬
quired for each day that the gestation had advanced; three units
sufficed for the first day but by the third or fourth day twenty units
were necessary to produce the result. L. Levin, P. A. Katzman and
Doisy found that in the last half of pregnancy neither theelin nor
theelol had any effect in producing abortion in the albino rat even
where given in very large dosage.

Edgar Allen, in a personal communication, stated that it has been
fairly well demonstrated that it takes excessive doses of folliculin to
produce abortion in laboratory animals. In testing for passage of
folliculin through the placenta, he submitted pregnant rats to fairly
high doses without terminating the pregnancy. Courrier and Kehl,
using rabbits, found that by injecting 20-40 R. IT. of folliculin the
greatest resistance to abortion was in the early days of gestation.
After the twelfth day less folliculin was required to produce abortion.
They believe this is due to the antagonistic effect of corpus luteum
in rabbits to the action of folliculin in the early stage of pregnancy.
How far these experiments may be applied to the woman remains to
be seen. It seems possible that where conception occurs shortly be¬
fore the menstrual period and the indications for abortion are funda¬
mentally present, injections of theelin or similar preparations in large
amounts within a few days after the period has been passed may at
times give the desired result. Future experience will determine
whether this method has any therapeutic value. According to Hof-
meister the experimental use of fresh testicular substance and
proprietary testicular extracts showed no definite effect in produc¬
ing abortion.

Pastes and Solutions. — The injection of pastes and solutions into
the uterine cavity by means of a syringe has long been used for pur¬
poses of abortion, but such methods cannot ordinarily be said to do
more than start contractions. The successful use in thousands of
cases of a special paste by the German druggist, Heiser, a professional
abortionist, led the Russian Commission to give it a trial. Genss told
me in 1930 that it had been used 55 times in Russian clinics but with¬
out decisive results. Recently as distinguished an obstetrician as
Sellheim said that he was testing its efficacy. It is claimed that the
uterus is evacuated spontaneously 24 hours after the injection.

Recent literature especially in Germany has been full of reports
concerning the dangers of using pastes to induce abortion. The very
simplicity of the procedure has added to these risks, since many
physicians, without obstetrical experience, have been tempted to use
it in private practice without proper technique or asepsis. Contrary

324

ABORTION

to Leunbach’s experience who found it necessary to curette only 12
patients out of 150 in whom he used his “Provokol” paste, we have
the report of Otto, who found that in only 8 out of 24 cases was the
evacuation complete. There was pronounced hemorrhage in 6 cases.
A further danger lies in the fact that the paste is introduced into the
uterine cavity forcibly by means of a pressure syringe. Engelmann
cites 5 deaths from air-embolism and 12 deaths from fat embolism
after the use of pastes. Autopsies done on two patients dying from
embolism after the injection of pastes showed, according to Brack,
infiltration of salve throughout the soft uterine wall, and lung emboli.
The cauterizing effect of these pastes has been repeatedly noted both
on the cervix, and in the uterine mucosa where they interfere with
normal involution. Schach in Prague cites a death from fat embolism
and records 25 similar fatalities in literature. According to Muller-
Hess and Hallermann deaths after the use of pastes are not due to
air-embolism attendant on faulty technique, but to fat embolism of
the salve itself. Fingerland believes the paste is forced into the
dilated veins through the contractions of the uterus. Where soap
solutions are used, Haselhorst and Schaltenbrand believe that death
is not due to air-embolism but to the entrance of soap solution into
the circulation, producing clot formations with great rapidity. Ap¬
parently abortion results from loosening the decidua from its attach¬
ment to the uterine wall (Fig. 118).

A few writers such as H. Wolf, Sachs and E. Will report favorable
results with the use of pastes, but they are far out-balanced by those
opposed. So strong has this feeling become in Germany that the
Federal Minister of the Interior has prohibited the use of such pastes
as Heiser’s, Interruptin, Antigravid, Provokol, Aretus and a vast array
of similar preparations, except by a physician’s prescription and upon
the physician’s responsibility as to the outcome. If further disastrous
results are reported from their use, it seems probable that their sale
and manufacture will be absolutely prohibited.

De Tarnowsky in this country has reported three cases of tuber¬
cular women in whom he used intrauterine injection of 3.75 c.c. of ether
to induce abortion. In each case the ovisac was expelled within 20
hours.

A simple measure, but of questionable efficacy, is the use of glycerine
vaginal tampons, suggested by Wittenberg. He found that they pro¬
duced cervical dilatation sufficient to start an abortion in 58 out of
60 cases. We agree that it is safer than the use of pastes, but doubt
whether others will get equally satisfactory results.

TECHNIQUE OF THERAPEUTIC ABORTION

325

It would seem that such methods are either dangerous or unreliable.
Certainly they will require further trial before they can be given
serious consideration.

Irradiation.— Of unquestioned value, where operative methods are
contraindicated and a period of temporary sterility is desired, is the
use of radiation to produce fetal death in utero and thus lead to
spontaneous expulsion of the ovisac. A number of important papers
have appeared on this subject. Ganzoni and Widmer, who have used
it extensively, stress as special advantages of this procedure that it
does not require narcosis, eliminates danger of infection and can be
done in bedridden patients. It was first employed by Krause, Schmidt

Fig. 118. — Uterus removed after injection of paste used for abortion. The paste
deposited in the lower uterine segment lifts the decidua from its point of attachment.
(E. Sachs: Zentralbl. f. Gynak., 1932.)

and Forsterling in 1914, but the results were disappointing owing to
insufficient dosage. The method as described by Stern and used at
Mt. Sinai Hospital in New York consists of a 50 to 60 per cent skin
unit dose with high voltage machine. The number of fields is de¬
termined by the number of portals of entry necessary to administer
the required depth dose. The voltage is 200 kilovolts, the milli-
amperage is 4, the distance usually 40-50 cm., and the filter always
0.5 mm. copper plus 1 mm. aluminum. No dermatitis was noted.
Similar results could doubtless be obtained by the use of large radium
packs (3 grams or more) in a manner similar to deep x-ray therapy,
though I am not aware that they have been so employed in any
radium clinics.

ABORTION

o o a
oZb

Experience has shown that this method is reasonably certain in its
results, but that, as Archangelsky points out, it is more suitable for
the first seven weeks of pregnancy. Stern would limit it to the first
fourteen weeks, since the percentage of failures is greatly increased
aftei the third month. Ganzoni and Widmer in 1925 reported 34
cases with 4 failures. Whenever unsuccessful, a curettage should be
done since the ovum is almost certain to show serious developmental
defects. In one case where permission to empty the uterus was re¬
fused, a microcephalic idiot was born. Out of 31 cases of therapeutic
abortion induced by x-ray reported by Stern, spontaneous expulsion
of the ovisac was noted 26 times (21 intact, 5 times fetus and placenta
separately). Of the remaining 5 patients 2 were curetted; one had
a hysteiotomy although the fetus showed evidence of death and might
later have been expelled; one showed placental changes that would
eventually have caused death ; and one case was definitely underdosed
in treatment. The usual interval between treatment and expulsion
was 14 to 42 days. There was usually very little pain or bleeding at
expulsion. The castration symptoms were usually milder than after
x-ray treatment of fibroids. Stern stresses the fact that one woman,
who refused x-ray treatment for abortion in place of operative meas¬
ures, died as a result of the latter. Wintz found that a considerable
interval of time, up to 128 days, often elapsed between irradiation
and expulsion of the ovum OAving to the tendency in these cases to
a missed abortion.

There would seem therefore to be a fairly definite, though rather
limited, field for employing this method of abortion. It is where the
abortion is to be done in the early months for a condition in which
operative measures are if possible to be avoided, and in which haste
is not a material consideration. Dangers of permanent sterility are
very remote and damage to any fetus that may be born in subsequent
pregnancies is most unlikely. No such late injurious effects have as
yet been noted.

Pathological examination of the expelled products usually show a
flattened, shrunken, slightly macerated fetus, a turbid amniotic fluid
and a slightly flaccid sac. The appearance is that of a missed abor¬
tion. Microscopic examination so1 far has failed to reveal any charac¬
teristic changes.

It may here be noted that though the ovaries are included in the
irradiated field in most of the cases, it is possible to obtain the same
result while partially shielding the ovaries. Harris hoav has a series

TECHNIQUE OF THERAPEUTIC ABORTION

327

of cases in which the ovaries have been excluded and in which the
amenorrhea has been of very short duration.

The method has been used extensively on the service of Robert
T. Frank, in very ill patients suffering from severe Graves 7 disease,
cardiovascular disease, renal disease, Parkinson’s syndrome, epilepsy,
active pulmonary tuberculosis and several other conditions. In view
of the absence of mortality and morbidity and in view of the favor¬
able effect of the amenorrhea, we feel that the method has some
advantages over surgical intervention. The length of time of amenor¬
rhea will depend, of course, upon the age of the patient. Roughly,
under 25 years of age, with the ovaries included in the field, the
amenorrhea should last from oue to two years. At the age of 35 or
over amenorrhea is likely to be permanent.

It is important to recognize that in addition to the physical exami¬
nation a careful psychological inventory should be made to determine
on the one hand the attitude of the woman to amenorrhea and pos¬
sible sterilization, and on the other to prepare her for such an eventu¬
ality by the reassurance that it will not produce ageing or lessen sex
desire. One cannot emphasize too strongly the necessity of careful
selection of cases, the strict following of indications, and the most
scrupulous attention to details of technique in the employment of this
method. These are necessary to secure one hundred per cent effi¬
ciency. It should go without saying that a careful check-up of the
apparatus by an expert physicist at periodic intervals is absolutely
essential.

To summarize, we record the method as an extremely valuable ad¬
dition to our gynecological armamentarium, if it is restricted to cases
in which all indications have been met, where the necessary accurately
tested apparatus is available and in which interruption by surgical
means appears extra-hazardous.

Surgical Procedures for Therapeutic Abortion

The simplest form of surgical procedure recommended for induction
of abortion is the aseptic puncture of the ovisac to let out the amniotic
fluid. This method is more suited to the later than to the early months.
It merely sets to work the mechanism by which uterine contractions
are produced, resulting in the gradual dilatation of the cervix and
expulsion of the uterine contents. Lovrich reported 120 cases with
no death where the ovisac was thus punctured to induce abortion.
Mayer also prefers it, wherever possible, in the fourth to the sixth
month of gestation. For most cases it will prove an uncertain method.

328

ABORTION

Stages of Therapeutic Abortion

The usual technique of therapeutic abortion may be subdivided into
three stages: (1) methods of dilating the cervix; (2) methods of

emptying the uterus; (3) methods of evacuation through a uterine
incision.

Methods of Dilating Cervix. — Three measures are employed for
dilatation in the early months of pregnancy : (1) metal dilators, (2)
laminaria tents; (3) gauze packs. In the recent special inquiry on
methods of inducing abortion, collected from 21 leading clinics in
Germany and Austria, it is apparent that dilatation with graduated
metal dilators is not as popular as the use of laminaria tents. Hoehne,
Stickel, Halban, Doederlein, Franz, Eymer, Peters and Novak favor
metal dilators, while Pankow, Fiith, Fraenkel, Peham, Frey, Mayer,
We id el, Zangemeister and many others favor laminaria tents. Opitz,
Henkel and Adler advocate gauze packs to promote cervical dilatation.
Some Germans and the majority of American obstetricians hesitate to
use laminaria tents because of the difficulty of complete sterilization.
Another disadvantage is the uncertainty of so applying them that the
entire cervical canal is dilated. Whitridge Williams favored the use
of metal dilators in most cases. In primiparae, or in patients that
requiie widei dilatation owing to the size of the ovisac, he preferred
to accomplish this either with a cervico-vaginal gauze pack or a
vaginal hysterotomy. DeLee considers laminaria tents dangerous.
Yaux, in the latest edition of Edgar’s Obstetrics, recommends either
metal dilators or a gauze pack applied to the lower uterine segment
as shown in Fig. 119. In England we find, however, that Munro Kerr
advises laminaria tents where slow dilatation is indicated.

Few Americans will agree with Levy-Lenz that therapeutic abortion
is a procedure that can be left in the hands of the general practitioner
to perform in his office or at the home of the patient. "With proper
limitation, according to indications already set forth, their number
or urgency is not so great but that all such patients can, and should,
be hospitalized so that the procedure may be done with the least risk
of complications.

In Russia experience has shown that under hospital conditions metal
dilatation can be done with uniform safety in the first three months
of gestation, certainly in all multiparae. The essential thing, of
course, is that the operative field be prepared and kept sterile as for
a suigical operation. It this is done, the slower methods of dilatation
will uot have to be employed in the earlier months. Levy-Lenz advises
dilatation up to 12 mm. for 1 month gestation, 15 mm. for 2 months
gestation and 22 mm. for 3 months gestation. In the choice of in-

TECHNIQUE OF THERAPEUTIC ABORTION

329

struments I prefer Hanks' dilators to the ordinary Ilegar type (Fig.
120), because the former have a greater forward curve, corresponding
to the normal anteflexed position of the pregnant uterus ; and because
the depth of introduction is gauged by a ridge on the dilator, so that
they do not slip in too far, and injure the posterior uterine wall. In
every instance, of course, the cervix must first be caught with a
tenaculum forceps and drawn down into the vaginal canal, so that
the angle between the cervix and vagina is straightened, and the
cervical canal held rigid for the dilatation.

Fig'. 119. — Use of uterine pack to stimulate contractions and bring about dilatation
of the cervix. The small tube packer through which the gauze is introduced is about
1 cm. in diameter and can readily be inserted after stretching of the canal with metal
dilators.

The technique of dilatation from the twelfth to the twenty-eighth
weeks of gestation is very different from that employed earlier. Here
we have a choice between gauze packs into the lower uterine segment
and cervix, the use of the bag, the metal metranoikter, and incision
operations. The necessity at this stage of development for a larger
opening through which the ovum can be expelled or extracted, is
apparent. Hence the use of instrumental dilatation in these cases will
hardly meet requirements. Most American obstetricians employ a firm
gauze pack in the lower uterine segment to stimulate contractions and
if these do not result in opening up the canal, a small rubber bag of
the Voorhees type is introduced and, occasionally with the assistance

330

ABORTION

of traction on the bag, the canal is dilated to a diameter of 3 to 5 cm.
In Germany we find obstetricians such as Opitz, Halban, Novak,
Peters, Franz, Pankow, Fiith, Fraenkel, Doederlein, Adler, Peham,
and Zangemeister all advising the use of the bag for dilatation (Fig.
121). A few, such as Ilenkel, Schroeder, Weibel and Frey prefer to
obtain access to the uterine cavity through vaginal or abdominal
incision.

Jolly Dilator, set of severu Heqar Dilafor. Z5- sues

duxm,. 3 rruru -to 3 Limn- ckam, . Zitub. fo 2Jo nun.

(One form, is doable -ended)

Double -ended Scnxrufs
Jet of Six ire 12- srz.es -

Metal U ter true D iladtons .

Fig. 120. — Metal dilators used in induction of abortion. Round graduated dilators
are less likely to produce tears than are the two-pronged instruments. The blunt,
only slightly curved dilators, designed by Jolly and Hegar, are more likely to per¬
forate the cervix than are the more pointed, more curved. Hanks type, that in addi¬
tion have a mark to indicate the depth of introduction. Particularly in the nulliparous
cervix with anteflexion should this type of dilator be preferred.

Emptying the Uterus.— The best method of emptying the uterus
after the cervix has been dilated has been, and still is, the subject of
heated controversy. Levy-Lenz insists that the average practitioner
must be trained to rely more on instruments than on his finger for
evacuating the uterus. The curette and ovum forceps should suffice
in a pregnancy up to the twelfth week, but after that period has been
passed, the guidance of the finger is essential to prevent excessive
hemorrhage or perforation. Perforation is indeed the complication

TECHNIQUE OF THERAPEUTIC ABORTION

331

most dreaded when instruments are used. In all instances a thorough
dilatation should precede their use, so that they can slip into the
uterine cavity without resistance. When a semi-sharp curette with
a large loop (1% cm. wide and 3 cm. long) is employed, the risk
of perforation in skilled hands is small, provided the pregnancy has
not advanced beyond eight to ten weeks (Fig. 122). While it may
not be possible to remove every portion of the ovum by this means,
the remaining particles of decidua are usually expelled without diffi¬
culty in the next day or two.

Fig. 121. — Voorhees bag used for dilating the cervix in pregnancies of four to six

months’ development.

The bleeding is rarely excessive in such early pregnancies. In the
third and fourth months, however, it is wiser to combine the ovum
forceps with the curette to remove the uterine contents. Details as
to the technique of such an evacuation can be found in Chapter XIII.
Here we need only to emphasize that the ovum forceps is not to be
employed to pull the ovisac from its attachment to the uterine wall,
but merely to remove large masses that have previously been loosened
and that are lying free in the uterine cavity.

If the cervix has been dilated to 2.5 cm. in diameter, a finger can
be introduced to determine whether there are still remaining portions
of the ovisac attached to the uterine wall. With a little practice the

332

ABORTION

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TECHNIQUE OF THERAPEUTIC ABORTION

333

finger can be trained to loosen sucli portions, so that they can subse¬
quently be grasped by the ovum forceps and extracted. In many cases
after the finger has thus been employed to loosen the placental attach¬
ment, the pieces of ovisac can be expressed from the uterus without
the use of any instrument. In such cases the simple sponge holder
with its oval open ends, is a convenient instrument for the removal
of smaller pieces. The use of local anesthesia (0.5 per cent novocain
solution with the addition of 3 drops of adrenalin to the ounce) into
the base of the broad ligament at either side of the cervix, together
with the injection of 0.5 c.c. of infundin into the uterine muscle, will
reduce the hemorrhage of such an evacuation to a minimum. Both
DeLee in America and Munro Iverr in England are convinced of the
greater safety of the finger over the curette. Physicians can be trained
to use their fingers for palpation and loosening of the placenta in a

relatively short time.

«/

The dangers of therapeutic abortion according to Levy-Lenz, are
divided between the risk of infection and perforation.

Risk of infection can be reduced to a minimum by the exclusion of
all cases of cervical infection, especially gonorrheal, until preliminary
treatment has cleared them up. Then, of course, we must employ the
strictest precautions as to asepsis and antisepsis, with shaving of the
vulva. The use of such antiseptics as acriflavine, mercurochrome, or
picric acid in the vagina and cervical canal will also decrease infection
risks. Equally important is the removal of the entire ovisac, so that
there is no opportunity for bacterial multiplication in the retained
necrotic placental tissue.

Perforations will rarely occur when the cervix has been thoroughly
opened, especially if, before operation, a bimanual examination be
made to determine the size and position of the uterus, and instruments
are used gently in the manner already described.

One-Stage or Two. — There is considerable argument as to the rela¬
tive advantages of the one-stage and the two-stage method of evacuat¬
ing the uterus. S. Topuse prefers to empty at one sitting; even though
there is greater risk of cervical tears, because of the lowered chance
of infection. After the third month of gestation, he removes the ovum
by vaginal hysterotomy. This was done in 145 cases without fatality.

In discussing the technique of therapeutic abortion employed with
162 patients, Spitzer found that in the 78 cases where the uterus was
emptied at one time from below, there was the lowest percentage of
infection, 5 per cent. In 31 cases abortion was done in two stages.
Finally there was a series of 51 cases of vaginal hysterotomy, one

334

ABORTION

.?;}§■• 123.— Vaginal hysterotomy for therapeutic abortion. (1)
1932 ?n t0 l00S6n va8'mal flaP over bladder and cervix. (Nelson’s

Semilunar vaginal
Looseleaf Surgery ,

Fig.

124. — Vaginal hysterotomy
the cervix.

for therapeutic abortion. (2) Sagittal incision through
(Nelson’s Looseleaf Surgery, 1932.)

TECHNIQUE OF THERAPEUTIC ABORTION

335

Fig-. 125. — Vaginal hysterotomy for therapeutic abortion. (3) Suture of the inci¬
sion through the cervix after evacuating the uterine cavity. (Nelson’s Looseleaf
Surgery, 1932.)

Fig. 126. — Vaginal hysterotomy for therapeutic abortion. (4) After removal of
the ovisac, the cervical canal is closed with interrupted catgut sutures, and the
vaginal flap fastened back at its original point. (Nelson’s Looseleaf Surgery, 1932.)

336

ABORTION

combined with sterilization and two cases of abdominal hysterotomy
done in more advanced pregnancies. Ail three of the deaths in this
series of 162 cases were due to the maternal disease and not to the
abortion. Spitzer quotes the following mortality statistics for thera¬
peutic abortion : Benthin, 244 cases with one per cent deaths ; Fuchs,

223 cases with 0.4 per cent deaths ; von Franque, 129 cases with 2 per
cent deaths.

Evacuation Through Uterine Incision.— Evacuation by uterine in¬
cision may be either a vaginal or abdominal procedure. The vaginal
operation may consist either of an anterior sagittal incision through
the cervix (Figs. 123-126) and lower uterine segment, or, having
opened the peritoneum by an anterior vaginal celiotomy, the uterus
may be incised above the cervix and the ovisac pulled out through
this opening. Whenever the operation is thus done vaginally, it
should be restricted to the multiparous woman with somewhat lax
floor, in whom the pregnancy has not advanced beyond the third
month. If done under these conditions, the operation is relatively
simple foi one trained in vaginal work ; and it can be combined
with a tubal sterilization procedure, if this is indicated in the par¬
ticular case. Bengolea, has done such a vaginal celiotomy successfully
with incision of the uterus nine times ; and Irving reports satisfactory
lesults in five patients where such technique was employed. Irving
used sacral anesthesia in his cases. Winter prefers incision of the
cervix as in cases of vaginal Cesarean section, pushing the bladder
back, to gain a higher approach into the uterine cavity. Occasionally
in pregnancy up to the fifth or sixth month a posterior cervical in¬
cision will also be required. No attempt at sterilization is made in
this operation.

A more radical vaginal procedure than any heretofore described
is the vaginal hysterectomy, recommended by Hornung, in cases where
a cessation of menstruation is also desired, as in certain cases of tuber¬
culosis in multiparous women. Hornung did 43 such operations in
Kiel from 1922-1928 without a fatality. The procedure was done
under twiliglit-local anesthesia.

The abdominal operation for therapeutic abortion has been recom¬
mended by Newell and Frommer in this country and by Perez, Gall,
Pawl ova and Goldschmidt abroad. This procedure is particularly
suitable in primiparae with a pregnancy advanced between the thir¬
teenth to twenty-eighth week, where sterilization is to be done
simultaneously (Figs. 127-129). Pawl ova and Gall prefer the trans¬
verse Pfannenstiel incision through the abdominal skin and fascia.

TECHNIQUE OF THERAPEUTIC ABORTION

337

Pawlova had one death from heart disease out of 25 cases. Perez had
one septic death in 42 operations, half of which were done for social-
economic indications. Frommer did 14 operations, 6 under local and
8 under spinal anesthesia. lie claims that emptying the uterus by
abdominal section is less of a physical strain than the ordinary vaginal
therapeutic abortion. Improvements in operative technique and an-

Fig. 127. — Abdominal hysterotomy for abortion in the middle trimester of preg¬
nancy. (1) After median incision, two stay sutures are placed through the uterine
wall to the right of the mid-line. (Irving: Am. J. Obst. and Gynec., 1923).

Fig. 128. — Abdominal hysterotomy. (2) Sagittal incision of the uterus between the
two stay sutures. (Irving: Am. J. Obst. and Gynec., 1923.)

esthesia, together with the frequent desirability of associating the
abortion with sterilization has led to more frequent adoption of such
incision procedures.

Selection of the Method of Induction. — Since the foregoing pages
may have left some confusion as to the best method of emptying the

338

ABORTION

uterus, I shall now try to set down briefly certain generally accepted
dicta about the factors influencing selection, which include:

(1) the indication for abortion;

(2) the parity of the patient;

(3) the stage of the pregnancy; and

(4) the skill and experience of the physician.

Fig-. 129. — Abdominal hysterotomy. (3) The uterus is emptied of its contents and
after transfixing- the uterine wall by means of two sharp knitting needles to keep it
approximated to the abdomined incision, the uterine cut is closed in layers with
special attention to the overlapping- serosal stitch as shown in the lower, left-hand
corner. (Irving: Am. J. Obst. and Gynec., 1923.)

(1) In cases where rapid emptying of the uterus is demanded, as
in beginning toxemia accompanying hyperemesis, impending diabetic
coma, uremia, eclampsia, serious heart decompensation, we must em¬
ploy metal dilatation and curettage, or one of the operations involving
incision into the uterus, with immediate evacuation. If, however,

TECHNIQUE OF THERAPEUTIC ABORTION

339

there is no need for such haste, we can employ either gauze pack or
laminaria tents in earlier pregnancies, and the bag or bougie in more
advanced ones.

(2) The parity of the patient materially influences the dilatation
of the cervix. Metal dilatation is usually recommended in the multip¬
arous individuals, while gauze packs or laminaria tents are employed
in the longer and more rigid cervix of the woman who is pregnant for
the first time.

(3) The stage of the pregnancy, as already indicated, is of great
importance in the choice of methods. In the first eight weeks of
gestation, opening the cervix with metal dilators and emptying the
uterus with a curette will be generally accepted as the best method.

Outline C. Methods for Therapeutic Abortion

FIRST TO EIGHTH

NINTH TO SIXTEENTH

SEVENTEENTH TO

WEEK

TWENTY-EIGHTH WEEK

RAPID

METHOD

Metal dilatation of
cervix.

Curettage of uterine
cavity.

Metal dilatation of

cervix.

Emptying uterus with
finger, sponge for¬
ceps, and curette.

Vaginal hysterotomy
or abdominal hyster-
otom y, with instru¬
mental evacuation un¬
der control of finger.

Utero-cervical gauze
pack.

Rubber bag dilatation
of cervix; followed
by spontaneous evac-

Same as above.

If not expelled spon¬
taneously, r e m o v e
w i t li sponge forceps

u a t i o n, assisted by
digital removal of
placenta when neces-

SLOW

METHOD

and c u r e 1 1 e under
guidance of finger.

sary.

In the following eight weeks (9-1 6tli week) the preferable method
will be metal dilatation to 25 mm. or the utero-cervical gauze pack
preliminary to an evacuation with the finger, sponge forceps or ovum
forceps, and curette. From the seventeenth to the twenty-eight week
we would suggest bag dilatation of the cervix, followed by spontaneous
evacuation of the ovisac, when haste is not required and vaginal or
abdominal hysterectomy where rapid emptying of the uterus is indicated.

(4) The skill and experience of the physician will limit the extent
of operative procedures. Only trained obstetricians should attempt any
of the incision procedures, since the danger of hemorrhage, or injury
to surrounding organs would be too great in unskilled hands. Levy-
Lenz claims that, for the average practitioner, the curette is safer
than the finger in emptying the uterus but this is not generally ac-

340

ABORTION

cepted as true. I should personally feel that any physician, who takes
the responsibility of a case of abortion, should train himself in the
technique of digital palpation of the uterine cavity.

In Outline C. I have tried to present in a graphic way the choice
of methods for the varying conditions that are found. Naturally for
the sake of clarity this selection is somewhat arbitrary and based on
American experience. For this reason the use of laminaria tents has
not been included.

CHAPTER XXI

PREVENTIVE ME AS URES— STERILIZATION

Preventive Measures

IN THE PRECEDING chapters the disastrous, oftentimes fatal, com-
* plications attending induced abortion have been described. Certain
measures are of course available for mitigating their severity but
fundamentally it must be self-evident that the best way to prevent
these complications is to prevent the occurrence of the undesired
pregnancy. Spontaneous abortion is a relatively minor accident. It
is induced abortion, both therapeutic and illegal, that presents the
grave dangers. If in these cases the pregnancy had been prevented,
the desire or need for interrupting it would not have arisen.

Conception can be prevented in various ways.

The simplest of these is sexual abstinence ; but, in married life, this
is, to say the least, impractical.

Another plan is restriction of sexual relations to the so-called “safe
period,” recommended by certain Catholic agencies. While some re¬
duction in the total number of children can reasonably be expected
by this procedure, it is too unreliable to be given serious consideration
as the sole method of restricting conception.

A third group of measures for avoiding pregnancy are the chemical
and mechanical measures employed in association with marital rela¬
tions. It is beyond the scope of this book to discuss these methods in
detail. Considerable progress has been made in recent years by sci¬
entific research upon this subject, and at the meeting of the American
Medical Association held in 1935 it was finally decided to have the Board
of Trustees appoint a special committee to study the entire problem.
Since we are still far from having discovered the ideal method for
avoiding pregnancy that is suitable for the poor and ignorant, who
need it most, it is to be hoped that the research of the next few years
will find for us a safer and more practical procedure. Measures em¬
ployed at present give from 60 to 95 per cent safety depending on the
intelligence and persistent care used by the married couple.

Physicians can find a full discussion of these methods in the fol¬
lowing publications :

Eric C. Matsner: “The Technique of Contraception,” Pamphlet, 38
pp., Williams and Wilkins Co.

341

342

ABORTION

14. L. Dickinson and L. S. Bryant: “The Control of Conception/ ' 290
pp., Williams and Wilkins Co., 1931.

Finally, there is a group of so-called “sterilization” measures
which act either upon the sex glands or the sex ducts to make con¬
ception impossible for longer or shorter periods of time. These meas¬
ures have the advantage that they are more or less permanent and
have no influence on marital relations.

STERILIZATION

When the prevention of conception is desired either permanently
or for long periods of time, and when for special reasons greater cer¬
tainty of success is demanded, we must resort to sterilization either
temporary or complete. This does not imply that the sex glands must
be removed. These sterilizing procedures in no way interfere with
sex functions. In fact such sterilization operations have been found
rather to increase than to diminish the completeness of sexual life,
since the inhibitions associated with the fear of an undesired preg¬
nancy that often attend normal intercourse, however safeguarded, are
no longer present.

Non-Surgical Procedures

Hormonal Treatment. — The desire to accomplish this result without
the necessity of surgical intervention has led many to attempt the
use of endocrine products that will either interfere with ovulation or
will inhibit or destroy the motility of sperm cells that gain entrance
into the female genital tract. Most of the work that has been done
thus far is based on animal experimentation. Haberlandt was suc¬
cessful in producing temporary sterility by injections of female sex
hormone. Kowacs has attempted testicular transplantation. Zondek
has used anterior pituitary extract. In Russia some of these measures
have been used in human beings with fairly satisfactory results. Much
additional investigation must, however, be done before we can give
this method serious consideration. I concur in Reis' criticism that
the prolonged use of extracts that tend to disturb the normal balance
of the endocrine secretions cannot be regarded lightly. The chances
for the discovery of a method that would be both certain and harm¬
less is not great.

Radiation. — Mention was made in Chapter XX of the use of the
x-ray in the non-surgical induction of abortion. An amplification of
this radiation to produce temporary amenorrhea with resulting sterility
has been recommended. In those cases where even a slight surgical

PREVENTIVE MEASURES - STERILIZATION

343

procedure would carry with it the risk of increased mortality, as
with heart disease or diabetes, we must give this method of sterili¬
zation serious consideration. Experience has shown that in women
over forty years of age such sterilization with radiation is more apt
to be permanent than in younger individuals. Where the individual
to be sterilized is of this age and the disturbances of a premature
menopause are no contraindication, we should give preference to this
simple procedure. Fear of a deformity in the child, should a pregnancy
take place in succeeding years, is not justified by clinical experience.
The great objection to its more widespread use is the uncertainty of
radiation results in any particular case. There are individuals whose
ovaries show marked resistance to radiation even in large doses. At
the first re-appearance of a menstrual-like flow, the treatment must
be repeated, or surgical measures employed.

Surgical Sterilization

While we shall discuss here only those operations that are done on
the woman, it is well to bear in mind, in considering the problem of
any given couple, that the simplest procedure is that of vasectomy on
the husband. The fact that it does not require hospitalization, is
perfectly harmless, and does not in any way inhibit the sexual func¬
tion of the male should make it the preferable procedure in a large
group of cases. Practically, however, it is as yet difficult to persuade
many men to undergo this slight sacrifice for the sake of their wives.
There are also conditions in which later marriage of the man is a
possibility to be weighed.

The vast array of operations that have been devised for steriliza¬
tion in women make it difficult to discuss this subject with any degree
of completeness. The construction of a double vagina recommended
by Zomakion and Haendly, one narrow passage ventrally connected
with the cervix for the menstrual flow and one dorsal canal for coitus,
is mentioned only to be discarded for evident technical difficulties.
Pocketing the ovaries beneath the peritoneum of the cul-de-sac is
shown to lead to serious disturbances of function and is an extensive
operative procedure. The remaining procedures all deal with some
method of blocking the passage of sperm and ovum through the Fal¬
lopian tubes. The operations suggested consist of ligation of the tube,
partial or complete excision, extra-peritonealization of the fimbriated
end, intra-uterine cauterization of the isthmic portion, or a combina¬
tion of these methods.

Tubal ligation, first employed by Blondel in 1823, and more fre¬
quently employed b}r Diihrssen and Kelirer toward the end of the last

344

ABORTION

century, was found to be very unreliable. Continuity was not infre¬
quently re-established, even where the tube was cut between the liga¬
tures. The healthy tube of fertile women is in this respect very
different from the diseased tubes of those less fertile individuals upon
whom even a successful salpingostomy with patency is not followed
by a pregnancy. It was necessary therefore to resort to more radical
procedures. Complete double salpingectomy has been done in many
cases but because of its danger of interference with ovarian circulation
is not recommended. It is an unnecessarily extensive procedure and
depends for success upon the careful excision and closure of the
uterine end.

Of the various operations that deserve careful consideration we can
distinguish two groups:

(1) Those intended for permanent sterilization.

(2) Those designed to make possible a re-establishment of the patency
of the tubes if a pregnancy is later desired.

Permanent Sterilization

Operations for 'permanent sterilization may be divided into four
groups :

(1) Crushing of a loop of the tubes followed by ligation.

(2) Excision of the isthmic portion of the tubes with peritonealiza-
tion of both ends.

(3) Severing the tube about one inch from the uterus and trans¬
planting the uterine end beneath the peritoneum or within a uterine
incision.

(4) Excision of the entire cornual portion of the tube with careful
closure of the uterine wound.

(1) Crushing Loop Operation, — The advantages of this method sug¬
gested by Madlener and modified by Walthard (Fig. 130) lies in its
simplicity and in the fact that it has been successful in the very large
series in which it has been employed. In several cases where the
tubes were later removed in connection with other operations and
studied microscopically, the satisfactory results could be explained by
the complete destruction of the tubal mucosa in the crushed area.
Saenger found that adding his own 620 cases to Madlener ’s 166 cases
and Gianella’s 604 cases from Walthard ’s clinic, there was but one
failure in 1,390 operations ; certainly to be designated as a satisfactory
result. Saenger stresses the importance of using an 8 mm. wide entero-
tribe without corrugations to crush the tubes and picking up a large
loop of the tubes as advised by Walthard. Other operators have,

PREVENTIVE MEASURES - STERILIZATION

345

however, not been so successful, so that Fraenkel, collecting 5 failures
from various reports, terms it an insecure procedure.

(2) Resection of Tubes with Peritonealization. — Some operators pre¬
fer to ligate the tube near the uterus, and after incising the peritoneum
over the tube, resect about 3-4 cm. of it. A very careful suturing of
the peritoneum over the two ligated ends effectively covers them and
prevents the passage of sperm or ovum from one portion of the tube
to the other (Fig. 131). Satisfactory results have been obtained with
this technique in several thousand cases in institutions for the insane
and feebleminded in this country.

1 Madlener method; tube lifted,

Z Madlener method; ligature in
groove made bg ecrasear

Fig-. 130. — Macllener operation for tubal sterilization with the addition of Walt-
hard’s modification, according to which a larger loop of the tube is crushed and then
ligated.

(3) Burying the Severed Uterine End of the Tube in the Uterine
Wall.— Ii •ving plunges an artery forceps beneath the peritoneum and
outer uterine wall at the cornual angle to make a canal into which
is drawn the ligated uterine end of the tube. In this way about 2 cm.
of the tube are buried deeply in the anterior uterine wall and fastened
there by several sutures. The distal end of the severed tube is covered
by the peritoneum of the broad ligament. When this type of opera¬
tion is combined with a therapeutic abortion, II. Fuchs prefers to im-

346

ABORTION

plant the severed end of the tube directly into the fundal incision
through which the ovum has been evacuated. It is claimed for this
operation that utero-abdominal fistulae are less likely to occur and
that few sutures are required. The method has not as yet been used
long enough to determine results, but is worthy of further trial.

(4) Excision of the Uterine Cornua. — It is logical to assume that
closure of the tube can most readily be accomplished at its narrowest
portion. Among gynecologists a widely adopted technique of tubal
sterilization is therefore based on the excision of the uterine cornua
containing the interstitial portion of the tube. A disadvantage of this

1. Incision through peritoneum. 3. Sutur inp irieiSTori.

Fig. 131. — Resection of a segment of the tube near the uterus with peritonealization of

the two ends for purposes of sterilization.

method lies in the increased bleeding and longer time required in its
performance. The occasional failures reported by this method can
probably be ascribed to faulty technique. Particularly are mistakes
and hemorrhages likely to occur where the sterilization is done vagi-
nally with undue haste and improper exposure. The excision of the
uterine cornua should include not merely a small wedge but the
greater part of the interstitial portion of the tube and the wound
should be closed in layers with separate peritoneal sutures as recently
described by P. Tliiessen (Fig. 132). My own modification of this
technique, as shown in Fig. 133, consists of further fortifying the seal-

PREVENTIVE MEASURES - STERILIZATION

347

ing of the uterine wound by catching the round ligament with its
peritoneal fold and suturing over this wound. Since many of these
cases are multiparae, the folding over of the round ligament has the
added advantage of elevating and holding forward the sagging uterus.

Fraenkel after reviewing all methods of sterilization concludes that
excision of the tubal cornua has given the most satisfactory results.
Reis compares results obtained by cornual excision with those follow¬
ing the Walthard-Madlener type of operation at the Michael Reese

1 Exsection of wedge at cormi.

Z Cross sect ion; diagram
of conrn.

osiu'e

Fig". 132. — Cornual excision of the interstitial portion of the tube with suture of the

uterine wound in layers.

Hospital (1925-1931). He found that with the same operators there
were 91 cornual operations without a failure and 49 Madlener opera¬
tions with two known subsequent pregnancies.

Reversible Operations for Temporary Sterilization

Between the two extremes of simple contraceptive measures on the
one hand and permanent sterilization on the other, we find a small
but definite group of patients in whom it is desirable to obtain the
certainty of operative sterilization for a period of time without mak¬
ing it impossible for them ever again to have children. In certain
cases of tuberculosis and other systemic diseases, the physical condi-

348

ABORTION

tion of the patient may after a time show such marked improvement
as to make pregnancy no longer contra-indicated. It also happens
occasionally that the death of children early in life makes the mother
willing to take renewed risks for the sake of not being left childless.
Finally we have a group of persons who should be sterilized but are
unwilling to agree to such measures if they are denied the possibility
of changing their minds at some later time. For such individuals
surgical measures have been suggested that effectively block the tubal
passages without destroying their continuity and so enable the surgeon
at a later time to re-establish patency by a second operation.

1. Interstitial and isthmian portions of 2. Ligated end of remaining portion. of
tube removed . Ligature ui cornu not Labe drawn down ajxd suiurexL between

3. Round Ligament is suf-ured over t-fre
Cat m cornu, cove ring this and the
opening in. the broad VgamenT

Fig-. 133. — Cornual excision method of Taussig-. The essential features of this
operation are : the complete excision of interstitial and isthmic portions of the tube,
the repair of the uterine wound in layers, the reduplication of the round ligament
with its peritoneum over the uterine wound, and the burying of the distal ligated
end of the tube between the folds of the broad ligament.

The chief of these so-called “reversible” operations for temporary
sterilization may be grouped under two heads :

(1) those in which the ampulla of the tube is buried beneath the
pelvic peritoneum

(2) those in which the ampulla of the tube is drawn into the
inguinal canal and anchored there extraperitoneally.

In the first of these operations a peritoneal pocket in which the end
of the tube is lodged is constructed usually between the bladder and

349

PREVENTIVE

MEASURES - STERILIZATION

the uterus. In Littauer's operation the tubes are drawn forward be¬
neath a puncture wound under the round ligament and sutured to¬
gether in front of the uterus; then they are covered by the vesical
peritoneum. In a recent cervical Cesarean section where temporary
sterilization was indicated I found no difficulty in attaching the
ampulla of the tubes over the lower uterine segment and covering
them by a fold of the bladder peritoneum. This technique corresponds
to the operation of Alfieri which Francesco lias used in 30 cases with¬
out a failure.

In the inguinal operation of Menge and Stoeckel a short incision
is made over the inguinal canal as in the Alexander operation for
retroverted uterus. The peritoneum is then opened at the internal
ring to pick up the end of the Fallopian tube and draw it out of the
abdomen. The small opening in the peritoneum is then closed tightly
around the tube. Since there is some pull upon the tubes, these should
be firmly anchored to the fascia of the inguinal canal. The procedure
is repeated on the opposite side through a separate incision. This
operation has the advantage that the peritoneal cavity is invaded only
momentarily and the operative risk is thereby reduced.

Tubal Coagulation

Dickinson and others have advocated a method of intra-uterine
electro-coagulation of the tubal cornua with production of a stricture
that seals the entrance of the tubes into the uterus. Sterilization by
this method has the advantage that it can be done in the office or clinic
dispensary without an anesthetic. As failures are reported in about
10 per cent in over a hundred cases, further tests must be made before
it can be accepted as a secure method of sealing the tubes. The treat¬
ment is given soon after a menstrual period, and both sides may be
done at, one sitting (Fig. 134). A description of the technique is given
in Dickinson and Bryant's “ Control of Conception," page 134. With
training in the use of the hysteroscope, it may become possible to
visualize the opening of the tubes and make for greater accuracy of
cauterization and even for a re-opening of the strictured tubes if
pregnancy should later be desired.

Causes of Failure

With the use of almost any of these newer methods of tubal occlu¬
sion, the number of unsuccessful cases is extremely small. While the
older methods of ligation and section had from 5 to 10 per cent of
failures, the newer sterilization technique has only a fraction of one
per cent of failures. Even this is too high, however, when we consider

350

ABORTION

tlie importance of absolute prohibition of pregnancy in many of these
cases. Analysis of the failures is therefore of some value. In the
Madlener operation the obliterated ends of the tubes are closely ap¬
proximated and if the obliteration is incomplete, the lumen may be
re-established. In the cornual operation the occasional development

lT£<Si:iNO

Cfiuferv

control

cervLX.

Colls r
on slides
prevents

per! ora
Mioti-bv

tip eiDoW

rs:-

' f stricture

srsfK

PROPUCED AT

ENTRY »f TUBE.
INTO UTERUS

L-fluivty COri'
tr o \ burn.hai
fee qqui a, f If in
tissue.

....... - - - - -

Tig-. 134.— —Dickinson’s method of electro-coagulation of the tubal cornua. Sterili-
zation can thereby be accomplished without resort to hospitalization or operation.
(Dickinson and Bryant.)

of a utero-abdominal fistula is due to superficial excision and inac¬
curate closure of the uterine wound. When the technique of Thiessen
with the addition of my plication of the round ligament is employed,
it seems a physical impossibility for any fistula to develop. Many of
the failures are associated with the vaginal operations for steriliza-

PREVENTIVE MEASURES - STERILIZATION

351

tion. Unless the pelvic floor is relaxed and the uterus can be drawn
down into the vagina so as to allow for good exposure of the uterine
portion of the tube, accurate closure is difficult and therefore insecure.
In most cases it is better to make a small abdominal incision and see
clearly the structures that are to be resected and sutured.

Choice of Method

When the physical condition of the patient makes it desirable to
do the shortest, simplest operation possible, the Madlener operation is
to be preferred. In all other cases cornual excision with careful
closure in layers is the safer and hence better procedure. Where
sterilization is to be done at the time of a therapeutic abortion it is
better to do both uterine evacuation and tubal closure through an
abdominal incision. Only in very obese patients or in the presence of
marked pelvic relaxation is the vaginal route to be preferred. If
permanent sterilization is to be done with a therapeutic abortion, the
fundal incision with excision of the interstitial part of the tubes gives
the best results. If temporary sterilization is desired, a sagittal cut
is made in the anterior wall to evacuate the uterus followed by the
Littauer or Alfieri operation. For temporary sterilization alone with¬
out abortion, the Menge operation has the advantage of being prac¬
tically an extraperitoneal procedure.

CHAPTER XXII

METHODS AND ACCIDENTS OF ILLEGAL ABORTION

IN THE EFFORT to rid themselves of undesired pregnancies, women
* have in the past employed almost every known poison and every
conceivable type of instrument. Merely to list, without comment, the
various measures that have been utilized would take many pages of
this monograph. In his book “Die Fruchtabtreibung durch Gifte und
andere Mittel, ” Prof. L. Lewin has recorded a vast literature and
any one who wishes more detailed information on this phase of the
abortion problem would do well to consult his volume of 523 pages.
I shall mention only a few of the more common drugs and methods
employed, since the vast majority of these have no specific abortifa-
cient properties and belong more properly in a volume on toxicology.
In fact, a considerable portion of our knowledge of poisonous drugs
is derived from the human experiments made upon themselves by
women desirous of an abortion. It is an evidence of the desperate
state of mind of these women that they so willingly face self-
destruction in their efforts to terminate a pregnancy. Success awaits
them in but a small portion of cases. Yet, decade after decade, they
continue to try anything that has been recommended. Of late, how¬
ever, particularly in the larger towns and cities, instrumental inter¬
ference by a trained abortionist has largely replaced the haphazard
use of drugs and homemade appliances.

Abortifacients

The measures employed to bring about an illegal abortion may be
considered under three heads :

(1) Drugs,

(2) Physical agents,

(3) Genital instrumentation.

Drugs. — Greater accessibility of vegetable drugs in a pure form has
led to their wide employment in preference to either animal or mineral
preparations. In former generations when the vast majority of people
lived in the country, it was a simple matter for the women to go out
into the woods and fields and pick the berries, leaves or roots of such
plants as, according to old wives" tales, would “bring them around”
if they were pregnant. The brews and concoctions suggested for this

352

METHODS AND ACCIDENTS OF ILLEGAL ABORTION

353

purpose were innumerable, but here and there chance came upon some
drugs that seemed more frequently to bring about the desired result.

Of these ergot of rye was one of the most popular, and its definite
action in stimulating uterine contractions has made it the recognized
agent for controlling postpartum bleeding. All clinical experience
has shown definitely that its effect is reliable only if the pregnancy is
at or near term, and the uterus already in a condition to respond to
irritation by contraction for other reasons. In the early months when
the interruption is most often desired, it is successful only in less
robust women with a tendency to spontaneous abortion. It is one of
the less dangerous ecbolic drugs.

The efficacy of quinine in strengthening contractions that have al¬
ready begun is undeniable, especially in the latter half of a pregnancy,
but according to Haberda, only exceptionally will a woman be found
so sensitive to it as to abort without some other contributing cause.
Large quantities up to 70 or 80 grains have been taken at times as an
abortifacient without result.

More poisonous in their effect are such drugs as oil of savm (Juniper
sabina). This popular agent for abortion has been used since ancient
times. Lewin in reviewing the literature records 21 cases in which
abortion was produced by means of this drug, but was followed in
nine instances by the death of the patient. In eleven additional cases the
drug failed to interrupt the pregnancy, but killed four of the women
who took it. The pronounced purgative effect of aloes has led to its
use in abortion, although with but scanty success, and in some cases
serious illness and even death have resulted. Other herbs that have
been recommended for this purpose are saffron, thyme, cloves, hel¬
lebore, sassafras, rue and hydrastis.

Tobacco, as mentioned in the chapter on Etiology, has apparently
some increased tendency to produce abortion when it is absorbed over
a long period of time by workers in tobacco factories, but has no
immediate effect as an abortifacient drug.

In rural America tansy tea is the favorite remedy. It is relatively
harmless, with only an occasional death reported, but it is also almost
invariably useless unless other measures are also employed or the
patient is unusually predisposed to abortion.

From recent literature it would seem that apiol (parsley) is now
the popular drug. Joachimoglu believes that its abortifacient action
is sufficiently definite to make it advisable to prohibit the sale of this
drug without a physician’s prescription. Its effect is that of the
drastic purges. Guttmann warns against the popular use of apiol,
since it contains a poison that in large doses produces nerve paralysis.

354

ABORTION

one with polyneuritis, both conditions having an unfavorable prognosis.

Many inorganic drugs also have been employed illegally for inter¬
rupting pregnancy. Metals, such as lead, mercury, copper, arsenic
and phosphorus, produce their effect indirectly by toxic action upon
the kidneys and intestines.

Lead is the most important of this group since it unquestionably
has a specific deleterious effect upon the chorionic epithelium (Fig.
135). This leads to fetal death and abortion in a high percentage of
workers in the lead industry. The harmful effects of lead can be seen
even in those children who have been carried to term. Lewin gives

Fig. 135. — Destructive effect of lead on the fetal epithelium of animals. (Blair-

Bell, London Lancet, 1924.)

as illustration the results of 123 pregnancies among lead workers, 64
of which ended in abortion, 9 in dead premature births, 35 children
dying within the first three years, and only 15 surviving. An English
report states that 239 mothers who, before being employed in the lead
industry, had had 487 pregnancies with 34 abortions, were found after
being so employed, to have 566 pregnancies with 67 abortions. There
was therefore an increase from 7 to 12 per cent in abortions as a
result of their new occupation.

The knowledge of this abortifacient action of lead has conduced to
its widespread use by midwives and druggists as an agent to inter¬
rupt pregnancy. In the form of diachylon pills containing mainly

355

METHODS AND ACCIDENTS OF

ILLEGAL ABORTION

oleate of lead , it lias been widely used in England, and according to
Parry, efforts are being made to control their sale since cases of lead
poisoning confined chiefly to women of the childbearing period in the
neighborhood of Nottingham led to an investigation that showed
diachylon was the main ingredient in “Mrs. 8 eag raves’ Pills/ ’ a
popular abortifacient. Mrs. Seagraves, alias Warded, was subse¬
quently convicted of producing abortions by this means. The terrible
consequences of taking diachylon pills are illustrated by Parry in the
history of an unmarried girl aged twenty-two, who took them for
delayed menstruation. She was attacked with symptoms of lead
encephalopathy, from which she eventually recovered, but remained
completely blind as a result of optic atrophy. The Pharmaceutical
Journal for August, 1934, contains an account of the current legisla¬
tion on this subject in Great Britain.

In Sweden, where phosphorus has been largely used in the manu¬
facture of matches, we find many cases in which match heads were
eaten to bring on abortion. While pregnancy was often terminated
by this means, it almost always led to jaundice and severe toxic symp¬
toms, with occasional fatal outcome.

Of animal poisons commonly used for abortion, mention should be
made of cantharides (Spanish Fly) and snake venom. They usually
fail to interrupt the pregnancy, but are highly toxic. More effective
are the pituitary extracts , although these are difficult for the laity to
obtain in sufficient quantity to bring about an abortion.

Physical Agencies. — Less popular with the laity are various forms
of external mechanical or thermic trauma to bring on uterine contrac¬
tions. A hot foot bath or hot sitz-batli is occasionally used in combi¬
nation with other measures, but rarely produces results. Excessive
exercises, jumping, gymnastics, carrying heavy objects, rough auto¬
mobile rides, etc., are resorted to. More effective is direct trauma to
the abdomen, such as jumping or pounding upon it, as employed by
savage races, but such injuries are usually ineffective except in more
advanced pregnancy and may lead to a premature separation of the
placenta, with serious consequences. Electric shocks by means of a
static machine may, in women whose uterus is easily aroused to con¬
traction, terminate in miscarriage. On the other hand, as noted be¬
fore, we have innumerable examples of women who have endured the
most severe physical and nervous shocks without any effect upon
their pregnancy.

Genital Instrumentation. — Vaginal applications, suppositories and
douches are but little more effective than the external measures al¬
ready mentioned. If, however, the instrument or medicine is brought

356

ABORTION

within the uterine cavity, it is apt to bring about the abortion. Among
the poorer classes who cannot afford to go to an abortionist, various
devices have been utilized to gain this object. Many women who wish
to have no more children train themselves to feel for the location of
the cervical orifice, and without any effort toward sterilization, slip
instruments within the cervical canal and successfully terminate their
pregnancy. A whole galaxy of instruments have been used for this
purpose (Fig. 136), from goose feathers, crochet needles and pen¬
holders to hatpins and catheters.

In America slippery elm tents are used, with or without the assistance
of a midwife. In Roumania, malven roots with a string attached are
commonly applied to the cervix. These agents, like laminaria, swell
up with moisture and dilate the cervical canal, thus bringing on an
abortion. In Hungary, pine needles, and in Slovakia thorns are a
favorite means of rupturing the membranes and producing abortion.

Fig-. 136. — Collection of instruments for illeg-al abortion sold in Paris.

In recent years the long stem, or spring type of intrauterine pes¬
sary has often been introduced by the abortionist to bring on abor¬
tions. Its use as an agent to prevent conception makes it readily
available for this other purpose, when desired.

The professional unskilled abortionist, whether midwife or char¬
latan, depends largely upon the intrauterine syringe for success in
his or her maneuvers. Soap solutions or glycerine are injected as
a rule, and only rarely is the measure taken of the amount of the
injected fluid. To the danger of infection by unsterile instruments
and the local cauterizing effect of the injected fluid, we have the added
risk of forcing some of the fluid through the tubes into the abdominal
cavity. If the second party to the abortion is more timid, he or she
may prefer merely to introduce a soft catheter into the uterus. This
should suffice to start the abortion, but occasionally it produces no
effect ; many cases are on record where the catheter has been delivered

METHODS AND ACCIDENTS OF ILLEGAL ABORTION

357

at term with the baby, or if a uterine perforation has been made,
has been found years later in the abdominal cavity.

Abortion Attempts in the Absence of Uterine Pregnancy. — A very
considerable number of cases are described in which either the preg¬
nancy is in the tube instead of the uterus, or the patient is not even
pregnant, but merely amenorrheic. The attempt to bring on an abor¬
tion under these conditions is likely to lead to serious accidents. The
abortionist meeting with failure at the first attempt is inclined to
repeat the procedures, each time with greater violence and greater
risk of perforation and infection.

Magid and Pantschenko have recently summarized some of the litera¬
ture on induced abortion in tubal pregnancy . They cite 81 such cases
reported by Zeitlin and refer to the article by Gruzdew, who from
personal experience found that intrauterine attempts at abortion had
been made in 15 out of 180 cases of ectopic pregnancy. In their own
series of observations Magid and Pantschenko found that in the course
of nine years 51 cases of attempted abortion had occurred in 726 tubal
pregnancies. Infections are less commonly noted in reports from Rus¬
sian sources, since there the attempted abortion is done in a hospital
by a physician. In other countries where such technique is not
routinely employed, serious and often fatal complications ensue. No
accurate tabulation of these infected ectopic deaths exists, but their
number must be considerable.

Many cases are also on record in which instrumentation for pur¬
poses of abortion was done in women who were not pregnant. Lie-
beck, in 1913, gave a list of 49 such cases, 18 of which ended fatally.
Many cases have since been reported, but the vast majority never get
beyond the knowledge of the midwife who has made the mistake. In
cross-questioning patients concerning previous abortions it is quite
common to get a history that clearly points to temporary hypofunction
of the ovary, simulating pregnancy. The patient desiring an abortion
under these circumstances goes to a midwife, who by her manipula¬
tions produces a slight flow of blood and tells the patient everything
has come away. Professional abortionists take advantage of the fears
of these women by telling them they are pregnant, when they are
reasonably certain that this is not the case, in order to get an extra
fee for a curettement. When the patient herself employs instruments
in the absence of pregnancy, serious accidents are apt to occur. The
absence of softening leads to the employment of more force. In
Zikmund’s case the bougie broke off leaving the stump in the uterus.
This stump subsequently worked its way through the uterus and was
recovered by operation in the epigastric region.

358

ABORTION

Accidents of Illegal Abortion

Perforation of the uterus, the most frequent type of injury resulting
from illegal abortion, lias already been considered in a previous
chapter. Neighboring organs are, however, also traumatized occa¬
sionally by the inept manipulations of the patient or attendant.
Catheters and bougies have, by mistake, been slipped into the bladder
and later required operative removal. A deep injury to the vaginal
portion of the cervix by means of a screw driver was recently re-

Fig-. 137. — Physometra of the uterus due to gas bacillus infection. (Brtitt. )

ported bir F. Muller. Vesico-vaginal and recto-vaginal fistulae may
result from crushing or perforating instruments used in these illegal
procedures.

Even greater is the risk due to the introduction of infectious organ¬
isms. The pathological processes resulting from infections by the
ordinary septic organisms have already been described in Chapter
XIV. Owing to the uncleanliness and type of instrument employed
by many patients it may happen that tetanus bacilli are introduced.
The mortality of these tetanus cases is even greater than that of
virulent streptococcus infections. G. II. Schneider, reviewing the

METHODS AND ACCIDENTS OF ILLEGAL ABORTION

359

literature, found 111 cases (including two of his own) with 91 per
cent mortality. Both of his cases ended fatally in spite of tetanus
antitoxin, and the addition of a hysterectomy. Since the outcome is
hopeless when the disease lias already manifested itself, Schneider ad¬
vises 'prophylactic administration of tetanus antitoxin whenever the
history suggests a reasonable possibility of contamination with earth,
dust from the streets, or animal excreta. Liebhardt calls attention to
the uncertainty of bacteriologic findings and the difficulty of finding
tetanus bacilli in the secretions, since they do not multiply rapidly.

Infection with the gas producing organism of Welch and Fraenkel
is almost equally serious. E. Strassmann describes as typical of this

Fig. 138. — Microscopic section of case of physometra shown in Fig. 147.

(Brutt.)

infection, icterus, cyanosis, and scanty brownish-black urine. rlhe
color of the urine is due to the hemolytic quality of this organism and
the hemoglobinuria. In the uterus it produces tympany with necrosis
of the retained portions of the ovisac. When the organisms penetrate
the uterine wall we have a crackling sensation on palpating the uterus,
due to physometra (Fig. 137). In a few cases there has been recovery
after drainage, with or without the addition of a hysterectomy. If,
however, the organism has entered the blood stream, the outcome is
always fatal in a short time, sometimes in a few hours. At autopsy
all the organs are found permeated with foamy material (Fig. 138).
Such postmortem changes in the organs cannot, however, be definitely

360

ABORTION

attributed to this organism, since they may be due to agonal changes
in the oxidation of the blood, permitting the invasion of gas-forming
saprophytes from the intestines. Extension of the infection to the
buttocks may produce large areas of superficial necrosis (Fig. 139).

Air-embolism is another frequent accident attending induced abor-
1 e c e n t e a i s, owing to the widespread popularity of inject¬
ing 'pastes into the uterine cavity by means of a powerful syringe, to
bring on an abortion, deaths from air-embolism have rapidly multi¬
plied. The subject of these pastes is discussed in greater detail under
the head of Therapeutic Abortion. Here we would especially mention
the many cases in which air-bubbles are introduced with the intra¬
uterine injection of soap solutions. A sell says that these soap-bubbles
may be sucked into the venous sinuses and carried to various organs.

Fig-. lo9. Bilateral gangrene of the buttocks associated with gas bacillus infec¬
tion following uterine abortion. (O. Schmidt: Zentralbl. f. Gynak., 1932.)

Experimental work done by Parade and other tends to the belief that
air alone entering the blood stream under normal conditions is not
as a rule dangerous. The combination with soap, however, is far more
serious. It happens at times that the air-embolism is localized in the
brain. Burgerhout relates the history of a twenty-three-year-old maid
found unconscious with instruments for abortion beside her. Definite
signs of paralysis, respiratory disturbances, eye symptoms, and gly¬
cosuria appeared. After ten days there was returning consciousness,
but after ten weeks still some amnesia. She finally recovered. Neller,
in discussing a similar case with definite brain lesion, claimed that the
statement that air cannot pass from the venous to the arterial system
in the lungs is false. He seeks to prove this by experiments. Pul¬
monary embolism with resulting lung infarction is, however, more
usual and if a larger vessel is blocked may result in sudden death.

CHAPTER XXIII

STATISTICS OF ABORTION

THE INTRODUCTORY chapter included an estimate of the ap¬
proximate number of abortions and deaths resulting therefrom in
the United States, each year. The figures arrived at, by the best means
at our disposal, were 681,600 abortions, with 8,179 deaths, or a death-
rate of 1.2 per one hundred abortions. These figures are believed to
be minimum, and are based not upon direct observation but upon in¬
ferences from the only data available. When we leave the general
inquiry into the total size of the problem and turn to studies of special
phases, we are on much safer ground, and find considerable help in
understanding the social aspects of the subject.

The following pages summarize the available statistical findings in
various countries regarding the relation of abortion to such factors
as population, puerperal mortality, childbirth, causative agents, age,
multiparity, legitimacy, race, religion, urban and rural life, and
preventability.

A few of the larger source tables, not essential to the text, have been
placed at the end of the volume in Appendix B. The most striking
fact in all these statistics is the evidence of the marked increase in
frequency of abortion in the last twenty-five years.

Relation to Population

The rate of abortion in any district may be calculated either on the
basis of the total population, or on the number of women of child¬
bearing years. The latter is called by Roesle the pre-fertility rate,
and is more valuable for comparative purposes as between rural and
urban areas, or between two periods of time, since local variations in
population make-up are obviated, such as the larger proportion of
young women to be found in any town, because of the influx of youth
from the country. Roesle shows that changes in abortion rate appear
quite different when calculated on the two bases, and cites the German
town of Magdeburg where a careful survey was made in 1912 and
again in 1927. The differences are shown in Table VIII where it ap¬
pears that there was a 4 per cent decline in the abortion rate from
1912 to 1927 when calculated on the total population, as compared
with a 12 per cent decline in abortions calculated on the pre-fertility
rate.

361

362

ABORTION

Table VIII

Abortion Rates : General Population and Pre-fertility in Magdeburg,

Germany, Comparing 1912 and 1927

(After Roesle : Statistische Jahrbuch ,der Stadt Magdeburg, fiir 1927)

(1)

(2) (3)

TOTAL POPULATION

(M (6)

ABORTION RATIO PER 1,000

YEAR

GENERAL

WOMEN OF

CHILDBEARING
years: 15-45

TOTAL

ABORTIONS

GENERAL

POPULATION

TO WOMEN OF

CHILDBEARING
years: 15-45

1912

1927

(Decline)

288,000

298,000

72,000

81,000

1,458

1,448

5.1

4.9

(4%)

20.3

17.9

(1*%)

For the city of Berlin, however, Roesle calculates that the pre¬
fertility rate was 31 per thousand in 1926 and 33 per thousand in
1927. A\ hen we compare the figures for Berlin in 1927 with those for
Magdeburg we see that the ratio was almost twice as large in Berlin.
Phis corresponds with the general belief that induced abortions are
particularly prevalent in the large metropolitan centers.

From Russia we have accurate figures on the population of Lenin¬
grad, and in the year 1926 we find that 21,646 abortions were regis¬
tered, a rate of 44 per thousand women between fifteen and forty-five
years of age. While these figures exceed those of Berlin, the difference
may be an apparent rather than a real one, since it is fairly certain
that large numbers of criminal abortions fail to be recorded in the
Berlin calculation.

Birth Rate. — Engelsmann, in extensive statistics from the city of
Kiel, contended that there is no decrease in the number of pregnancies
but that the decrease in the birth rate is brought about by the increase
in abortions. Specially significant is the decrease in the number of
children among fertile families ; and also the fact that while the per¬
centage of births is still highest in the laboring classes, these also
have the highest percentage of abortions.

This influence of abortions upon the birth rate has been emphasized
with some justice in the Soviet government reports. Dr. A. B. Genss,
the official statistician on this subject, points out that while between
1910 and 1927 the birth rate in England dropped from 28.4 to 16.7 per
thousand (a decrease of 41 per cent), and in Germany it dropped from
34.7 to 18.3 (a decrease of 47 per cent), and while all the other
European countries showed a similar decline, the Russian birth rate
had only declined from 47.2 per thousand in 1910 to 44 in 1927, thus
remaining by far the highest for all Europe.

Legalization of abortion, Genss points out further, has not produced
in Soviet Russia any material decline in the birth rate. In illustration
of this he cites the figures from Moscow in 1913 and in 1926. In 1913

STATISTICS OP ABORTION

363

the birth rate was 32 per thousand, while in 1926 it was 29 per thou¬
sand. On a basis of 2,019,453 population in 1926 a continuance of the
birth rate of 1913 would have produced 66,000 children. In fact
58,384 children were born that year. There remains, therefore, a
deficit of 7,000 children or 3 per thousand. Now the index of abor¬
tions was 16 per thousand in 1926 in comparison with 3 per thousand
in 1913. If we add the 3 per thousand of 1913 and another 3 per
thousand which represents the true increase in abortions, we get 6
per thousand as against 16 actually observed. With some justice
Genss interprets the difference between these two figures, amounting
to 10 per thousand abortions, as the correct figure for the secret
unregistered abortions. His claim, therefore, is that, instead of there
being over five times the rate of abortions in 1926, as compared with
1913, the true increase with legalized abortion amounted to but 3.4
per thousand, approximately 30 per cent. Genss7 figures are of course
based on the assumption that there has been no increase in the per¬
centage of conceptions, and if we consider the extensive birth control
propaganda in Russia, we can I believe fairly assume that, even in
spite of ostensibly laxer moral conditions, there has been no increase
in the ratio of conceptions.

One of the best statistical studies on abortion, although limited in
its numbers, has recently come from the Swedish city of Mahno.
Lindquist analyzes in great detail 2,047 abortions from 1898 to 1927
with the following general conclusions :

(1) The number of abortions in Sweden in 1920 showed a 27 per
cent increase over 1913, whereas confinements were only 10 per cent
greater.

(2) The decrease in the married fertility ratio (children per 1,000
married women of 17 to 45 years) was from 245 in 1908 to 90 in 1927.
This decrease was only slightly influenced by increased abortions.

(3) The decrease
19 in 1927 is lar

in the unmarried fertility ratio from
gely explained by increased abortions.

1908

Registered abortions increased from 121

in 1910 to 282 in 1927.

From New York City we have definite evidence of the increasing
number of abortions. Illegal abortions are reported to the Depart¬
ment of Health from hospitals, dispensaries and other sources. Dr.
Kahn notes a gradual increase between 1926 and 1929, with a drop
in 1930 and a considerable increase by 1933 :

1926

1,350

1929

2,568

1927

1,783

1930

2,313

1928

- 2,380

1933

5,197

364

ABORTION

Dr. Kahn’s report is confirmed by the survey of puerperal mortality
in New Y ork for the three years 1930 to 1932 made under the direction
of a special committee of the New York Academy of Medicine. This
study which excluded cases classified as “criminal abortions’* (p. 52)
showed that the death-rate from abortion had nearly doubled in these
years. (See Table IX.)

Table IX

Abortion Death-Rates for Three Years in New York City (1930-1932)
(From Maternal Mortality in New York City, 1933, p. 54)

YEAR

(1)

TOTAL

DEATHS

(2)

DEATHS

FOLLOWING

ABORTION

(3)

PER CENT

ALL DEATHS

(4)

RATIO PER
1,000

LIVE BIRTHS

Total Three Years

2,041

357

17.5

1.0

1930

675

13.5

0.7

1931

708

127

17.9

1.1

1932

658

139

21.1

1.3

In the analysis of 2,09/ abortions observed in the Cincinnati Gen¬
et al Hospital from 1918 to 1932, W. M. Millar found that while the
marriage index in Cincinnati rose during this period from 100 to 137
and the birth index increased from 100 to only 104, there was a jump
in the abortion index from 100 to 361. This increased frequency was
most pronounced in the years from 1928 to 1932, for with a decrease
in the number of births from 9,062 to 8,261, there was an increase in

the number of abortions at the Cincinnati General Hospital from 171
to 278.

In Australia, Worrall quotes the report of the Director General of
Public Health to the effect that the number of abortions have increased
at a startling rate, from 11 per cent of all female patients treated in
192b to 15 per cent in 1931. In the latter year there were treated at
the Royal Northern Coast Hospital, 904 abortions, with 29 deaths.

Ratio of Abortions to Confinements

The studies of Kopp, Macomber and Plass, quoted in the first chapter,
indicate a ratio of one abortion to two and a half confinements in the
cities, and one to five in the country districts. In Williams’ text book
on obstetrics the ratio is given as one abortion to four or five confine¬
ments. A similar estimate (1 to 5.9) is given by Whitehouse for
England.

More complete data are available from Germany, where the ratio
given by Schottelius for Hamburg in 1919 was 8,707 abortions to
16,779 confinements, or a ratio of one to two. Nevermann followed

STATISTICS OF ABORTION

365

up these figures in Hamburg and found that by 1925 the ratio had
increased to two abortions to three confinements. While the abortions
had increased from 8,707 to 12,000, the births had only risen from
16,779 to 17,600. Heynemann is convinced that the ratio of abortions
to confinements has steadily increased until at the present time in
Hamburg the number of abortions equals those of full-term confine¬
ments.

The summary, in Table X, of births and miscarriages in all German
Maternities from 1902 to 1930, shows a relatively low proportion of
abortions; but this does not represent the actual rate in Germany
since the great majority of inductions are done illegally, and outside
the hospitals. Even these incomplete figures, however, indicate a
steady increase in frequency, from a ratio of 3 interruptions to each
100 births in 1902 to 16 in 1930, the most marked difference being
between the periods immediately preceding and following the War.

Table X

Abortions Recorded in German Maternities, 1902 to 1930
(J. A. M. A. 102: No. 9, 1934.)

(1)

PERIOD

(2)

TOTAL normal

AND

PREMATURE BIRTHS

(3)

TOTAL

ABORTIONS

(4)

RATIO ABORTIONS

100 BIRTHS

1902-1904

104,757

3,357

1911-1913

190,471

8,466

1917-1919

164,707

19,222

1920

83,024

8,027

1923

70,413

8,681

1924

79,964

10,679

1925

102,227

11,319

1926

110,751

12,354

1927

113,632

15,229

1928

123,445

18,924

1929

132,712

21,093

Latzko, in Vienna, found an even more marked increase, the ratio
of abortion to confinements increasing from 19 to 57 per 100, or
trebling between 1898 and 1913, as shown in Table XI.

Table XI

Ratio of Abortions to Confinements (Vienna)

(After Latzko: in Halban-Seitz Handbuch VII, 1, p. 561.)

(1)

YEAR

(2)

TOTAL

CONFINEMENTS

(3)

TOTAL

ABORTIONS

(4)

RATIO PER 100
CONFINEMENTS

1898

1,148

218

1908

1,894

613

1913

3,611

2,068

366

ABORTION

From Poland the figures are not quite so high. In Warsaw in 1921
there were 1,138 abortions and 3,403 confinements, a ratio of one to
three.

France, that has always had a rather low birth rate, is reported by
Balthazard, Lacassagne and Doleris to have an average of 500,000 to
600,000 abortions every year, making a proportion of practically one
interruption to every delivery.

According to Mme. Lebedeva, the average in the small towns of
Russia is about one abortion to four confinements, or 25 to 100 ; but
in the large cities, such as Moscow, it is 70 to 100; and in Leningrad
in 1929, there were recorded 38,500 confinements at term and 53,000
registered abortions, or a ratio of 138 abortions to 100 confinements.

Types of Abortion

The most general etiological grouping of abortions is by type,
whether spontaneous, therapeutic, or illegally induced. The third
type is the most common, according to all authorities, here and abroad,
the exact proportion varying according to the character of the popu¬
lation and the source of the figures.

Town and Country. — In large cities the proportion of criminal abor¬
tions may run as high as 75 to 80 per cent, while in the country dis¬
tricts the figures will appear lower. Heynemann for 1922 gives the
proportion of such abortions in Berlin as 89, Hamburg 70, and Munich
66 per cent. Plass in an inquiry among country practitioners in Iowa
and surrounding states, found that abortions were grouped as 34 per
cent spontaneous, 5 therapeutic and 61 criminal, among all reported
by 81 doctors with a combined maternity experience of about 51,000
deliveries.

A California report on 876 abortions, tabulated by C. A. Du Puy
of Highland Hospital, indicates a smaller proportion of induced, 340
(35 per cent) as compared with 566 spontaneous (58 per cent) and
70 of unknown origin (7 per cent).

Maternal Deaths. — When the computation is made on the basis of
maternal deaths following abortion, the percentage of those reported
as criminal is large, but not so large as when figures are gathered by
other means. The Children’s Bureau study of Maternal Mortality in
Fifteen States reports a total of 1,825 abortions, and among the 1,588
cases where the type was recorded, gives the distribution as 37 per
cent spontaneous, 13 therapeutic and 50 per cent criminal. It is fur¬
ther believed that most of the remaining 237 cases were probably

STATISTICS OF ABORTION

367

induced, judging from the high ratio of septic abortions among them,
which was nearly as high as among those recorded as induced. It is
noted by the Children’s Bureau that these figures cannot be taken as
representative of the distribution of types among abortion not re¬
sulting in death.

Clinic Figures. — As noted before, the data on abortion assembled
in birth control clinics are in some respects believed to reveal prevail¬
ing conditions more exactly than those from other sources, because
of the way in which they are gathered and the psychological factors
involved. Dr. Kopp’s book, “Birth Control in Practice,” presents more
details about more cases than have been analyzed elsewhere; and the
findings, being similar to those of other studies, may be taken as repre¬
sentative of reports from maternal health centers in general.

In the 10,000 case histories, 417 were of women who had never been
pregnant, and 9,583 of women who had been pregnant from one to
twenty times or more, with 38,985 pregnancies or about four apiece,
a quarter of all having had five or more. In all, 4,573 women reported
no abortions, and 5,010 reported one or more. Altogether there were
11,172 abortions or more than 28 per cent of the total number of
pregnancies. If to the abortions the 872 stillbirths are added, this
makes a total of 12,054 prenatal deaths or nearly a third of all the
pregnancies.

As to type, of the 11,172 abortions, 3,165 (28 per cent) were spon¬
taneous, or one in every twelve pregnancies; only 340 (3 per cent)
were therapeutic, an incidence of less than one per cent of the preg¬
nancies, leaving 7,677 (69 per cent) which were terminated deliberately.
This makes one induced abortion in every five 'pregnancies . Of these,
4,378, or one in 9 were terminated by a physician; 1,125, or one in 33,
by a midwife; and 1,863, or one in 25, by the woman herself. The
complete details are given in Source Table A in Appendix A, showing
the number of abortions in accordance with the order of pregnancy,
and the agent of termination ; and certain important features of the
situation are summarized in Table XII.

In “A Study of Pregnancy Wastage,” R. K. Stix reports an in¬
vestigation based on personal interviews of 991 women whose records
were obtained through the Birth Control Clinical Research Bureau
in the Borough of Bronx, New York, from Jan. 1, 1931, to June 30,
1932. This group was largely Jewish, and naturally did not include
women who had become sterile or had died of abortion. Her more
important findings were :

368

ABORTION

“Seventy per cent of pregnancies terminated in live births, 20 per
cent in illegal abortions, and the remaining 10 per cent in spontaneous
abortions, therapeutic abortions, ectopic pregnancies, and stillbirths.

“Catholic women had a higher percentage of live births and a lower
peicentage of illegal abortions than did the other religious groups,
but there were more illegal abortions per woman among Catholics
than among Jews.

The per cent of pregnancies illegally aborted increased as mar¬
riage lengthened, though because of increased use of contraceptives
the actual number of abortions was not higher in the later than in
the earlier periods of married life.

“The proportion of pregnancies terminated by illegal abortions in¬
creased rapidly during the past twenty-five years.’7

Table XII

Pregnancies and Abortions Reported by 10,000 Applicants for Birth Control

in New York City

(Summarized from M. E. Kopp: Birth Control in Practice, Source Table XXII

For details see App. B.)

(1)

order

preg¬

nancy

Total

First

Second

Third

Fourth

Fifth

Sixth

Seventh

Eighth

Ninth

Tenth

Eleventh

Twelfth

Thirteenth

Fourteenth

Fifteenth
and over

(2)

i— i

38,985 11,17

(3)

I— I

■<

(4) (5) (6) (7)

PER CENT OF PREGNANCIES
TERMINATED BY ABORTION
OF EACH TYPE

(8) (9) (10) (11)

PER CENT OF ABORTIONS*
INDUCED BY:

i—i

Cu,

Xfl

9,583

1,000

8,101

1,585

6,271

1,955

4,593

1,736

3,242

1,333

2,273

1,054

1,579

712

1,071

519

709

348

0.1

482

239

327

172

231

135

0.4

—

157

101

LJ^J

268

900

Lj Lj o

f -^u[Oor gives percentage of induced abortions bv each agent of induction in

of total pregnancies instead of in terms of total inductions as here given

STATISTICS OF ABORTION

369

Age of Mother and Number of Pregnancies

From the Children’s Bureau we quote the following statements on
age and parity, which are summarized in Table XIII, and detailed in
Source Table E. :

Table XIII

Age at Death of Women Who Died Following Abortion and From Other

Puerperal Causes

(Summary of Table 04 in Maternal Mortality in Fifteen States, Children's

Bureau Publication No. 223, p. Ill)

(1) (2) (3) (4) (5) (6)

PER CENT DISTRIBUTION BY AGE AT DEATH

AGE

TOTAL

FOLLOWING ABORTIONS OF EACH TYPE

NOT FOL-

PERIOD

DEATHS

ALL

CAUSES

TOTAL

REPORTED

SPON¬

TANEOUS

THERA¬

PEUTIC

IN¬

DUCED

LOWING

ABORTION

(Total, Age Beported)

(7,350)

(1,825)

including

un¬

classified

(589)

(205)

(794)

(5,525)

Under Fifteen Years

—

•X-

15, under 20

20, under 25

LJ lj

25, under 30

30, under 25

35, under 40

40 and over

*Less than 1 per cent.

“The proportion of the maternal deaths that were preceded by abor¬
tion increased with the age of the mother up to the age of 30 and
decreased thereafter. A larger proportion of the women who died
following abortion (45 per cent) than of all women dying from puer¬
peral causes (40 per cent) were from 25 to 34 years of age.

“More than half (52 per cent) of the spontaneous abortions occurred
at 30 years of age and over, as compared with 44 per cent of the
therapeutic abortions and 41 per cent of the induced. The age at
which the largest number of induced abortions occurred was from 25
to 29 years (26 per cent) ; of the therapeutic abortions, 20 to 24 (26
per cent) ; and of the spontaneous abortions, from 30 to 34 (24 per
cent). It is of interest that 12 per cent of the women who had in¬
duced abortions were under 20 years of age, as compared with 8 per
cent of those who had therapeutic or spontaneous abortions. The age
distribution of women whose deaths followed abortion but for whom
the type of abortion was not reported was practically identical with
that of women whose abortions were reported as induced.

“Abortions preceded the deaths of 18 per cent of the known primi-
parae and 26 per cent of the known multiparae in the study. Nearly
half (49 per cent) of the deaths of the 526 women of unknown parity
were preceded by abortions. Among the primiparae for whom type
of abortion was reported, 31 per cent ol the abortions were sponta¬
neous, as compared with 40 per cent among the multiparae. The

370

ABORTION

deaths of known primiparae were preceded in 8 per cent of the cases
by induced abortions, in 5 per cent by spontaneous abortions, and in
3 per cent by therapeutic abortions ; for 2 per cent the type of abor¬
tion was not reported. Among known multiparae death was preceded
by induced abortions in 11 per cent of the cases, by spontaneous abor¬
tions in 9 per cent, and by therapeutic abortions in 3 per cent; for
3 per cent the type tvas not reported ” (p. 111).

The New York Academy of Medicine report for 1930 to 1932 calls
attention to the fact that the larger percentage of abortion deaths

did not occur among the primigravidae or in the lowest age groups
but that this was found in the period from 35 to 39 years and in
women who had been pregnant six or seven times, as seen in Tables
XIV and XV.

Table XIV

Abortion Deaths by Age of Mother
(From Maternal Mortality in New York City, Table 16, p. 57)

(1)

(2)

(3)

ALL

ABORTION

PER, CENT OF

ACjrJli LrJtvVJ U r o

DEATHS

ALL DEATHS

Total

2,041

357

15 to 19

108

20 to 24

429

25 to 29

559

30 to 34

449

35 to 39

358

40 years and over
«/

138

Table XV

Abortion

Deaths by Gravidity

(From Maternal Mortality in New York City, Table 17, p. 58)

(1)

(2)

(3)

rj.r> A A7TT1 A TP

ALL

ABORTION

PER, CENT OF

DEATHS

ALL DEATHS

Total

2,041

357

867

134

351

III

236

176

115

VIII and over

127

Multigravidity not reported

Gravidity not reported

These figures, while suggestive, do not tell the whole story with
regard to age and parity because we do not know the distribution
of ages for all women delivered in any given year, nor the total de¬
liveries of each order of gravidity, or parity.

STATISTICS OF ABORTION

371

Corroborative evidence is obtained from Dr. Kopp’s statistics indi¬
cating that induced abortion is primarily a problem of the mother
with many children, the percentage steadily rising from 4 per cent in
the first pregnancy to 28 per cent in the fourth and 48 in all over the
ninth. While the physician Ts help to terminate pregnancy was sought
in 3 per cent of the total first pregnancies, this percentage rose to 8
in second pregnancy, to 13 per cent in the third and to 16, or over
five times as much in the fourth pregnancy. In the case of midwife
induction of abortion, these percentages rise from 1.5 in the first
pregnancy to eight times as much in the fourth pregnancy. The
natural desire of every woman to have a child is evidenced by the
fact that in the first pregnancy only one in nine was terminated be¬
fore viability and half of these were unintentional or spontaneous
abortions. On the other hand, when we come to the fourth pregnancy
we find that about one in three pregnancies ended as an abortion and
that over three-fourths of these abortions were intentional (Table
XII and Source Table A).

In Russia, where legalized induced abortion is discouraged among
primiparae, Genss has found that only 3 per cent occur below twenty
vears of age. In the larger towns the majority were in women be-
tween twenty and thirty years of age with one or two children, and
in the country districts the period of greatest frequency of abortion
was in women between thirty and forty years of age with three or
four children. In contrast to these figures are those given by Ivordo-
bovskij who found that 2,656 women with legal abortions in Lugansk
had an average of only 1.7 living children.

Genss gives us also some very interesting figures showing the dis¬
tribution of abortions and births to the age of mothers in the city of
Moscow in 1926, as shown in Table XVI. Here the abortion rate grows
steadily with age, so that after forty, nearly half of the pregnancies
are interrupted.

Table XVI

Abortion in Relation to Age of Mother (Moscow)
(After Genss: Abort auf dem Lande, 1926.)

AGE

GROUPS

(1)

NUMBER

WOMEN

(2)

TOTAL

BIRTHS

(3)

TOTAL

ABOR¬

TIONS

TOTAL

CONCEP¬

TIONS

(5) (6)

RATE PER 1,000

(7)

WOMEN

(8)

PER CENT OF

CONCEPTIONS

ENDING IN

ABORTION

BIRTHS

ABOR¬

TIONS

CONCEP¬

TIONS

All Ages

609,790

58,394

31,986

90,380

151

15-19

102,809

2,593

1,151

3,744

20-29

212,314

39,611

20,216

59,827

146

220

30-39

189,675

14,622

9,436

24,058

132

40-49

104,992

1,568

1,183

2,751

372

ABORTION

Relation to Marriage

The increase in the number of abortions, generally observed through¬
out the world, has been due less to laxity of morals than to underly¬
ing economic conditions. This is seen by the fact that the considerable
majority, of even the illegal abortions, occur in married rather than
unmarried women. Dame Louise Mcllroy, in a report submitted July,
1929, states that in England before the War induced abortion had
been mainly resorted to by unmarried women but that at present it
was most frequent among the married.

Among younger individuals, however, this is not the case. Thus
in Hamburg, Ofderdinger (1925) found that the percentage of illegiti¬
macy among women with abortions under twenty years of age was
63 per cent ; between twenty and twenty-five years, 40 per cent ; be¬
tween twenty-five and thirty years, 14 per cent; between thirty and
thirty-five years, 3.5 per cent; and between thirty-six and forty years,
1.6 per cent. In Breslau, Riechelt found (1930) that abortions were
more frequent among the unmarried, 1,179 of the patients being un¬
married and 691 married. Out of 201 confessed criminal abortions,
he found 174 were unmarried and 27 married.

In the United States, figures based on the maternal mortality
statistics are as follows: of the 1,825 women in fifteen states who died
following abortions, 186 or 10 per cent were unmarried, whereas, 1,638
women were married. In the NeAv York City report it was shown
that the deaths following abortions occurred in 16 per cent among
the married, as compared with 45 per cent among the unmarried preg¬
nant women. The total number of abortion deaths among the mar¬
ried was very much greater. In the Philadelphia report we find that
of the 162 deaths from septic abortion, 114 were of married women
and 48 were in illegitimate pregnancies. “This ratio of almost three
to one” says Dr. Williams, “indicates clearly that the cause of self-
induced or criminal abortion is not, as has been commonly believed,
the result of illegitimate pregnancies.”

In Lindqvist \s study of abortion in Mahno, Sweden, we find the
following statements: “A definite increase in abortion rate from 1910
to 1927 occurred in married multiparae, increasing with the number
of children. Approximately 10 per cent of abortions in I-parae are
criminal, 50 per cent in II-parae, and 80 to 90 per cent in women with
three or more children and in unmarried women. Among the unmar¬
ried, 90 per cent who had abortions were of the lowest and poorest
social strata. Factory workers under 20 years were the most common
type; but of the married women, abortion was not particularly com-

STATISTICS OF ABORTION

373

mon among women whose husbands belonged to the poorest classes.
The majority belonged to the lower middle class. ”

Roesle has made an interesting comparison between three small Ger¬
man towns (Magdeburg, Halle and Lubeck) and Leningrad, showing
the relation of abortion to the number of previous pregnancies among
the married and unmarried (Table XVII).

Table XVII

Abortion in Married and Unmarried : Reported Gravidity and Month of

Gestation

A. Distribution of Abortions According to Gravidity in Germany and Russia
(After Roesle: Statistische Jahrbucli tier Stadt Magdeburg, p. 125)

(1)

PLACE AND

PERIOD

(2)

MARITAL

STATUS

(3)

TOTAL

ABORTIONS

(4) (5) (6) (7)

PER CENT ABORTIONS IN GRAVIDAE

ill

IV AND

OVER

Magdeburg

Married

3,359

Ll Ll

(1925-1927)

Single

1,559

Halle

Married

3,015

(1919-1923)

Single

892

Lubeck

Married

606

(1925-1926)

Single

220

Leningrad

Married

9,976

(1925)

Single

3,162

B. Month of Gestation at Abortion, Reported in Vienna, Magdeburg and Halle
(From Peller: Fehlgeburt und Bevolkerungsfrage, Tab. XLVI, p. 140)

(1)

PLACE AND

PERIOD

(2)

MARITAL

STATUS

(3) (4) (5) (6) (7)

PER CENT ABORTIONS BY MONTH OF GESTATION

UP TO

SECOND

THIRD

FOURTH

FIFTH

SIXTH

AND OVER

Vienna

Married

LJ Li

(1900)

Single

(1912)

Married

Single

Magdeburg

Married

(1910-1913)

Single

Halle

Married

(1919-1923)

Single

L Li

In Germany the proportion of married women who abort their first
pregnancies was relatively high, from 7 to 12 per cent, as compared
with 4 per cent in Leningrad. Among married women with four or
more children, on the other hand, abortion was more frequent in

374

ABORTION

Russia than in Germany. The unmarried women in the German cities
brought on abortions in their first pregnancies in from 65 to 74 per
cent of the cases, whereas in Leningrad the absence of the marriage
tie did not impel women to resort to abortion as a shield, and it oc¬
curred in only 30 per cent of the first pregnancies.

Relation to Duration of Pregnancy

Since induced abortion increases in its dangers as the pregnancy
advances, and since spontaneous abortion is more frequent in the
second and third months owing to the fact that the ovum is not yet
so firmly attached to the uterus, it is not surprising that the incidence
of all types of abortion is very much greater in these months than
later. This difference lias been emphasized in Russia by the refusal
of the government to tolerate the induction of abortion after the third
month except under very rare conditions. Genss gives the interesting
figures shown in Table XVIII, indicating that under the old regime
the proportion of abortions after the third month amounted to nearly
one quarter of all secret or illegal abortions; whereas by 1926, even
the illegal abortions performed after the third month had declined to
13 per cent, while only one half of one per cent of the legal abortions
were produced in the fourth month or later.

Table XVIII

Comparative Distribution op Abortions According to Month of Gestation in
Kussia and in Magdeburg and Breslau, Germany

(After Genss, Roesle, and Kiist.ner)

(1)

PLACE, YEAR,

(2)

PER

(3) (4) (5) (6)

CENT IN EACH MONTH OF GESTATION

AND

TYPE OP ABORTION

FIRST

SECOND

THIRD

FOURTH

FIFTH AND

LATER

Russia

1912 Secret

0.5

1926 Illegal

1926 Legal

0.3

0.2

Germany

Magdeburg (Roesle)

0.4

Breslau (Kustner)

—

In Roesle s statistics from Magdeburg there was no appreciable dif¬
ference in time between the spontaneous and criminal abortions, both
types occurring as follows:

Month
First .
Second
Third
Fourth
Fifth .
Sixth .

Per Cent

— 0.4

__ 8.2
__ 33.6
__ 31.4
__ 15.9
7.2

STATISTICS OP ABORTION

375

Heynemann quotes 0. Kiistner who found among 1,571 cases at the
Breslau clinic the following distribution: in the second month, 25 per
cent; in the third, 48; in the fourth, 16; and the remaining 11 per
cent in the next two and a half months. These German figures have
been added to Genss’s in Table XVIII, to show the relative success
of the Russian policy of keeping abortions early, as reflected even in
the illegal cases.

Among 7,366 intentional interruptions, reported by Dr. Kopp, 27
per cent occurred in the first month ; more than twice as many, 58 per
cent, in the second month ; while 13 per cent waited till the third month ;
and only 2 per cent until the fourth month or later, to terminate the urn
desired pregnancies. The details in Table XIX show that spontaneous
and therapeutic abortions were relatively more advanced, 49 and 38
per cent, respectively, being in the third month or later, as compared
with 15 per cent of the induced.

Table XIX

Abortions by Agent of Termination According to Month of Gestation in Va¬
rious Types of Abortion

(After Kopp: Birtli Control in Practice, Modified from Master Table XXIX)

(1)

(2) (3) (4) (5) (6)

ABORTIONS IN EACH MONTH

(7) (8)

PER CENT IN

(9)

EACH

(10)

MONTH

TYPE OF ABORTION

AND AGENT

TOTAL

FIRST

SEC¬

OND

THIRD

FOURTH

AND

LATER

FIRST

SEC¬

OND

THIRD

FOURTH

AND

LATER

Total

10,533

9 999

5,602

1,994

715

1. Spontaneous

3,060

279

1,284

978

519

2. Therapeutic

307

159

3. Induced

7,166

1,910

4,159

929

168

By:

a. Physician

4.279

1,039

2,625

518

b. Midwife

1,108

292

608

173

c. Self

1,779

579

926

238

The Children’s Bureau figures on this point are also of interest. The
period of gestation was reported for 1,461 of the 1,825 women dying
after abortion (Table XX). In 38 per cent it was less than three
months; in 30 per cent, three months; in 15 per cent, four; and in 17
per cent, five or six months. More than half of the induced abortions
were in the first two months, as compared with a quarter of the spon¬
taneous, and an eighth of the therapeutic.

Relation to Religion

Religion does not seem to be an appreciable factor in restraint so
far as evidenced in the histories analyzed in New York City by Dr.
Kopp. AVhile out of 5,010 women who had aborted, 44 per cent were

ABORTION

Table XX

Period op Gestation Among Women Who Died Following Abortion op Each

Specified Type

(From Maternal Mortality in Fifteen States, Children's Bureau Pub. No. 223, p. 107)

gestation

Total

Period Reported, Total

Less Than Three Months
Three Months
Four Months
Five Months
Six Months
Period Not Reported

(1) (2)

(3) (4)

(5) (6)

(7) (8)

(9)

DEATHS FOLLOWING

ABORTION

OP EACH TYPE

TOTAL

SPON-

THERA-

TYPE

DEATHS

TANEOUS

PEUTIC

INDUCED

NOT

NUM- PER

RE-

BER CENT

PORTED

1,825

589 __

205 __

794 __

237

1,461 100

501 100

201 100

610 100

146

548
443 30

220 15

119

131

364

127

150

100

336

185

184

Jewish, 28 per cent were Protestant, and 26 per cent were Roman
Catholic, this was about the representation of these three religions
m the whole group studied. It was found that more Jewish and
Protestant than Catholic women had abortions, but it was observed
that a relatively large proportion of all the Catholic applicants re-
ported abortions, and they had had more abortions per capita than
eithei Protestants or Jews. The number per woman averaged 2.35
among the Catholics, 2.25 among the Jews and 2.20 among the Prot¬
estants. Source Table B, in Appendix B gives further details on this

subject. The per cent distribution among the various religious groups
is as follows :

TOTAL

PREGNANT

PER CENT OF

TOTAL WITH

ABORTIONS

WITH ABORTIONS
IN EACH GROUP

J ewish

Protestant

Roman Catholic

Other

In the group of patients, whose records were analyzed by R. K.
Stix, there had been 686 illegal abortions. Of these 509 (74 per cent)
weie done by a physician ; 135 (20 per cent) were done by a midwife ;
and 42 (6 per cent) were self-induced. It is of special interest that,
whereas among the Jewish group 88 per cent were done by a physi¬
cian, among the Catholic and Protestant groups these ranged from
49 to 51 per cent. Corollary to this, we find that among the Jewish

STATISTICS OF ABORTION

o nn

O I l

women only 7.5 per cent employed midwives, while about 41 per cent
employed midwives among the Catholic and Protestant women.

Relation to Race and to Urban or Rural Groups

Race. — The figures from the Children’s Bureau, for the United States,
as given in Table XXI, show 1,568 deaths following abortion among
white women and 257 deaths among colored women. Relating these
figures to the number of live births of white and colored in the years
and the states of the study, we find 15 deaths following abortion per
10,000 live births among white women as compared with 21 among
the colored, as shown in the accompanying chart in Fig. 140. The
excess among the colored consisted primarily of spontaneous abortions.
The death rates following spontaneous abortion were 4.5 among white
and 9.5 among the Negroes, per 10,000 live births. According to
Holmes, Mussey and Adair, this difference may in part be explained
by the frequency of myoma of the uterus in Negroes, and in part
laid to the poorer economic conditions, together with ignorance con¬
cerning principles of cleanliness, and to the improper medical care
rendered these colored patients. It is to be noted that the total rate
of maternal mortality among the colored was nearly twice that of the
whites, and that the deaths from abortion do not account for the
discrepancy.

Table XXI

Type of Abortion and Mortality Rate, Comparing White and Colored and Urban

and Rural Areas

(Rearranged from Table 65 in Maternal Mortality in Fifteen States, Children’s

Bureau Publication No. 223, p. 112)

COLOR AND AREA

(1)

ALL

TYPES

(2)

(3) (4)

ABORTIONS BY TYPE

SPON¬

TANEOUS

THERA¬

PEUTIC

INDUCED

NOT

REPORTED

Total Number

1,825

589

205

794

237

Rate per 10,000 Rive Births

15.5

5.0

1.7

6.7

2.0

White Women

1,568

474

189

729

176

Rate

14.8

4.5

1.8

6.9

1.7

Colored Women

257

115

Rate

21.3

9.5

1.3

5.4

5.1

In Urban Areas

993

274

103

488

128

Rate

21.5

5.9

2.2

10.6

2.8

In Rural Areas

832

315

102

306

109

Rate

11.6

4.4

1.4

4.3

1.5

In New York City, deaths following abortion among Negroes were
23 per cent of the total puerperal deaths in that race, while they were
only 17 per cent among the whites. In Philadelphia septic abortion
deaths occurred in 131 white women (22 per cent) and in 31 colored
women (26 per cent).

378

ABORTION

Urban and Rural Areas. — According to the Children’s Bureau statis¬
tics the mortality rate from abortion was higher in the urban than
in the rural districts, being 22 as compared with 12 per 10,000 live
births. As shown in Fig. 140, the difference was most marked in
induced abortions, where the rate was 11 in the urban areas, as com¬
pared with 4 in the rural districts.

In the United States, so far as our information goes, there is a
definite increase in the number of abortions in the large metropolitan
centers, whereas at least the one report by Dr. Plass from rural dis¬
tricts in the Midwest indicates that no noticeable increase lias occurred

MORTALITY RATES for DEATH FOLLOWING
ABORTION of VARIOUS TYPES

Induced

Spor\4cmeous TKerapeaKc Unspecified
^\\\\\\\n I I

“Rate per 10,000 Live Birlks

O 2 a- 6 8 lO 12. 14 16

< - • - ♦— i - 1 - I - 1 - 1 - -4-

Total , 16

-t-

3.0 2 2.

—I - (

Urban., 22

"Rural, U

WKite,15

Colored,24

HI 37

FHE-

1*7 3 5T

Fig. 140. — Comparative mortality rates following abortion of various types, among
white and colored women, and in urban and rural areas. (From Maternal Mortality
in Fifteen States, Children’s Bureau Publication No. 223, p. 112, 1934.)

in this area. These figures were obtained from 81 physicians, of whom
26 stated that there was an increase in abortions, and 55 stated that
there was no such increase. The division of abortion deaths accord¬
ing to the fifteen states studied in the report of the Children’s Bureau
showed that induced abortion was highest in the state of Washington
(23 per cent), and in other Pacific Coast States, and lowest in Alabama
(3 per cent).

In Czechoslovakia, however, a recent investigation by IT. Heclit
showed that abortions were about as frequent in the rural areas as
in Prague. Women of middle age reported on the average 3.8 abor-

STATISTICS OF ABORTION

379

tions apiece in Prague, and 3.5 in rural territories. The information
was obtained by direct questionnaire of 1,300 married women, two-
tliirds of whom were from rural areas.

There seems also to be a definite difference in the rural and urban
groups as to the factors justifying induction of abortion. Genss found
that in Russia illness was a much more common cause of legalized abor¬
tion in the country districts than in towns, 30 per cent compared with
19 per cent ; and that in the country districts the desire to conceal the
pregnancy was far greater (7 as compared with 2 per cent in the
cities). The figures given in the League of Nations report for 1930
show that in the Soviet Union the registration of abortions is less
complete in the country districts and that secret abortion is far more
common there. In eight provinces of Russia the number of legalized
abortions per thousand women showed striking differences, the regis¬
tration in urban areas amounting in tli e totals to over ten times the
rural rate (see Table XXII).

Table XXII

Age at Abortion in Urban and Rural Districts
Rates from Eight Provinces in the Soviet Union (After G-enss : )

AVERAGE RATE

OF ABORTIONS

AGE

PER 1,000 WOMEN

GROUPS

RURAL

URBAN

DISTRICTS

Total 15 to 49 years

3.38

35.40

Under 17 years

0.11

0.92

IS and 19

1.16

11.69

20 to 29

4.73

48.35

30 to 39

5.54

40.41

40 to 49

1.84

10.19

In Germany also, as indicated by the puerperal mortality figures,
we find that the incidence of abortion deaths was 2.1 per 1,000 in the
towns and 0.8 per 1,000 in the country.

Relation of Abortion to Puerperal Septicemia

United States.— In the studies of maternal mortality stimulated dur¬
ing the past few years by the White House Conferences on Child
Welfare, we find the statement made repeatedly that septic abortion
is the outstanding factor in keeping the puerperal death-rate so high.
Comparison of our puerperal mortality rates with those of countries
in which abortion rates are kept under a separate head is not justified.
Indeed, Adair, among others, raises the question whether deaths from
induced abortion should properly be included in our studies of puer¬
peral and infant mortality.

380

ABORTION

Maternal Mortality in Fifteen States. — In the completed report of
the Children’s Bureau (1934) the subject of abortion is given special
study. The following paragraph is italicized in the original (p. 103) :

“Probably the most outstanding finding of this study is that one-
fourth of all the maternal deaths followed abortion. Almost three-
fourths of the deaths following abortion were due to puerperal sep¬
ticemia, and these deaths from sepsis following abortion constituted
nearly half of all the deaths from septicemia, the greatest single cause
of maternal mortality

Puerperal septicemia tvas the cause of 1,324 or 73 per cent of the
1,825 deaths following abortion. Of the 794 deaths following induced
abortion, 722, or 91 per cent, were due to puerperal septicemia.

The deaths following abortions make a striking contribution to the
maternal mortality rates from puerperal septicemia, as shown in Fig.
141, where the proportion of septic deaths among all the deaths is
seen to be 40 per cent, but only 30 per cent of the non-abortion deaths
as compared with 73 per cent of those following abortion. Criminal
abortions caused one-fourth of all the deaths assigned to puerperal
septicemia.

In the lower part of the chart the distribution of deaths from septi¬
cemia following various types of abortion may be seen to vary from
21 per cent in the therapeutic, and 60 in the spontaneous, to 91 in the
induced cases. The high proportion of septic cases among the deaths
following abortion of unknown type indicates a strong probability
that these were largely induced. (See also Table XXIII.)

Table XXIII

Septic Abortion and Deaths by Type of Abortion
(Modified from Maternal Mortality in Fifteen States, Children’s Bur. Pub. 223,

p. 106)

TYPE OF

ABORTION

(1)

TOTAL

ABORTIONS

(2)

SEPTIC A

NUMBER

(3)

BORTIONS

PER CENT

Total

1,825

1,324

Spontaneous

589

354

Therapeutic

205

Induced

794

722

Type Not Deported

237

204

Puerperal septicemia was recorded as “ obvious and unmistakable7’
in connection with 2,948 of the total 7,380 maternal deaths. The 1,324
cases of septicemia following abortion thus constituted 44 per cent
of deaths from septicemia as compared with a total incidence of 25
per cent of abortion among all deaths, and indicate the special hazard
of abortion.

STATISTICS OF ABORTION

381

This connection was emphasized in the local reports from various
cities :

In “ Maternal Mortality in New York City,” it is stated that abor¬
tion deaths, 357 out of the 2,041 puerperal deaths, constituted 4 7.5

ABORTION 6 SEPTICEMIA A/WONG WOMEN
DYING FROM PUERPERAL CAUSES

FROM 15 STATES OF U SA-

TOTAL DEATHS
ALL CAUSES

INCIDENCE OF SEPTICEMIA BY TYPE OF ABORTION

THERAPEUTIC

ABORTION

TOTAL DEATHS 20T
NON-SEPTIC Lfol
SEPTIC AH

SPONTANEOUS

ABORTION

35H

TYPE NOT
REPORTED

237

2 04-

INDUCED

abortion

722. B1+F

Fig-. i4i. — Role of abortion and septicemia in maternal mortality. Lined portion
of each circle represents proportion of each group of deaths reported as septic. (Prom
data given in Maternal Mortality in Fifteen States, Children’s Bureau Publication No.
223.)

per cent of the total; and the incidence of septicemia in the con¬
fessedly induced cases reached 97 per cent, as shown in Table XXIV.
In this report the cases recorded as spontaneous predominated, as all
known illegal cases were omitted.

382

ABORTION

Table XXIV

Abortion Deaths by Type op Abortion and Incidence, op Septicemia
(From Maternal Mortality in New York City, Table 15, p. 55)

TYPE

ABORTION

(1) (2)

ABORTIONS

(3) (4)

WITHOUT

SEPTICEMIA

(5) (6)

WITH

SEPTICEMIA

NUMBER

PER CENT

NUMBER

PER CENT

NUMBER

PER CENT

Total

357

100

262

Spontaneous

192

134

Induced

108

105

Therapeutic

Type Unknown

In the Philadelphia review of Maternal Mortality from 1931 to 1933,
under the direction of P. P. Williams, we find the following statement :

One of the oustanding facts of this survey is that 22.5 per cent or
over one-fifth of the total deaths studied, 162 of the total 717, were
caused by septic abortions. Of the 639 puerperal causes of death, over
one-fourth came under this category” (p. 45). There were 188 deaths
following abortion, of which only 26 were noil-septic, and 162 were
septic. Of the 26 non-septic cases, 22 were spontaneous and 4 in¬
duced, while of the 162 septic cases interference of any kind was
denied in 57, leaving 105 that were induced. Of these, 56 were self-
induced, 46 were induced by some one other than the patient, and 3
were therapeutic abortions. Sixteen of the 46 criminal cases were
classified as homicides. In Williams’ opinion, a considerable number
of the septic cases in which interference was denied were probably
induced.

A brief report on maternal mortality in the city of Cleveland, dur¬
ing 1931, shows that, 50 out of the total 151 puerperal deaths, or one-
third were due to abortion. In over 70 per cent of these deaths
sepsis was the cause. Further points of interest in this report are
that practically all infected abortion patients die in hospitals, and
that out of nine puerperal deaths assigned to a midwife five were due
to septic abortion.

From Colorado a few statistics are available through the investiga¬
tions of E. D. Burkhard. From 1928 to 1932 inclusive there were 725
puerperal deaths, and of these 153 or 21 per cent were acknowledged
to be induced abortions. In addition to these cases a certain number
of the 257 deaths from puerperal septicemia can also be fairly at¬
tributed to abortion. Burkhard would have these deaths included as
homicides so that our maternal mortality rate could be cleared of this
unfair addition.

STATISTICS OF ABORTION

‘>Q‘>

ooo

Statistics gathered by L. R. Smith for 1927 in Michigan show that
abortions caused 231 of the total of 819 puerperal deaths or 28 per
cent; while the proportion of those dying from septicemia following
abortion was even higher, 181 out of 359 total septicemias, or 50 per
cent.

In the city of Magdeburg, Germany, we find that the death rate
from sepsis following abortion is seven times greater than that fol¬
lowing childbirth. In the years 1924 to 1927 there were in Magdeburg
17,382 confinements with 24 maternal deaths from sepsis, a ratio of
1.4 per 1,000 confinements. During the same four years there were
reported 6,497 abortions with 61 maternal deaths from sepsis, a ratio
of 9.4 per 1,000 abortions. We have also figures available from Berlin
for the years 1922 to 1926. These show that in 1922 out of 626 ma¬
ternal deaths from puerperal sepsis 503 (over 80 per cent) followed
abortion and for the five years, 1922 to 1926, the total was 2,387 ma¬
ternal deaths following sepsis of which 1,886 occurred after abortion,
or 79 per cent.

Naujoks (1927) found that in Koenigsberg, Prussia, the puerperal
sepsis mortality was divided between births and abortions as follows:

Births Abortions

1922 _ 123 503

1923 _ 100 459

1924 _ 89 389

Thus Avitli some absolute decline in death rate, the ratio of sepsis
deaths following abortions was 4 times as great as that following
childbirth.

Great Britain.— The Interim Report of the Departmental Committee
on Maternal Mortality and Morbidity (1930) showed an increase in
the ratio of deaths from abortion to total female deaths from 1.9 per
1,000 in the five-year period, 1919 to 1923, to 2.6 in the period from
1924 to 1928. Figures available for 1926, 1927, and 1928, on the pro¬
portion of abortion deaths to total puerperal mortality, show that there
were in 1926, 308 cases (11 per cent) ; in 1927, 297 cases (11 per cent) ;
and in 1928, 301 cases (10 per cent). The 1928 figures did not include
57 coroners’ cases which would have brought the total to 358 cases.
Even so, the British figures are considerably lower than those in the
United States and Germany.

From Switzerland we have unusually complete reports giving the
comparative death rate following childbirth and abortion. These
figures show that during the last thirty years, the number of births
has decreased from 97,028 to 69,006, and that the rate of maternal

384

ABORTION

mortality following puerperal fever has been reduced by one-half.
On the other hand, deaths due to abortion still remain at a high level
and exceed 20 per thousand stillbirths. (For details see Appendix
B, Source Table C.)

Relation to Preventability

One of the most interesting features of the New York report was
the effort made to analyze maternal deaths according to preventabil¬
ity. The question whether a particular death was or was not pre¬
ventable is difficult to answer, and the resulting judgment must be
taken as the opinion of the committee in charge of the investigation
and not necessarily final. Naturally when it came to abortion the
percentage judged to be preventable was very high. Abortion deaths
were divided into therapeutic abortions 47, of which 32, or over two-
thirds, were said to be preventable, and other abortion deaths 310,
of which 239, over three-quarters, were preventable. Dividing these
preventable deaths according to the responsible agent we find that in
the therapeutic abortions the physician was blamed 28 times and the
patient 4 times. The other 310 abortions, including a large number
of septic cases, showed that responsibility rested upon the physician
in 41 cases (17 per cent), upon the patient in 197 cases (82 per cent)
and ascribed to the midwife in one case. It should be recalled again
that the New York report did not include known cases of “criminal
abortion. ”

The Analysis Committee in the Philadelphia report found that in
the 26 non-septic abortion deaths, one-half were preventable, 6 times
due to the doctor, 7 times due to the patient. Of the septic abortion
deaths 76 per cent (123 out of 162) were preventable, and respon¬
sibility was ascribed in 15 cases to the physician, and in the remaining
108 cases (88 per cent) to the patient. The latter group consisted of
the illegal abortions in which the patient directly or through a second
party secured the operation.

A quotation from this report is of interest, as showing the compli¬
cated nature of the material and the difficulty of arriving at an ac¬
ceptable judgment :

“The Analysis Committee regarded the following case as an ex¬
ample of error in technic on the part of the physician. A woman, a
little over two months pregnant, had an apparently spontaneous abor¬
tion at home and was referred to the hospital because of bleeding.
Pieces of placenta were removed from the cervix digitally and the
vagina was packed. The following day a curettement was done.
Within two days a febrile reaction occurred, becoming septic in type.

STATISTICS OP ABORTION

385

A right-sided mass developed. Repeated transfusions were given as
well as other supportive measures but death followed in a few weeks.

“The Analysis Committee selected the next case to illustrate error
in judgment on the part of the physician. A woman had repeated
hemorrhage during the third month of pregnancy. The vagina was
packed on admission to the hospital. Two days later a dilatation and
evacuation was attempted but was unsuccessful as the cervix was hard
to dilate, but the history stated the uterus was packed. On the third
day a dilatation and evacuation was done and a transfusion was given
for hemorrhage. The patient developed a septic temperature and died
on the eleventh day after the final operation. This case was one of
a number where the uterine cavity was entered more than once.

“In placing the responsibility upon the patient, the Analysis Com¬
mittee attributed such deaths as the following, to ignorance of the
probable results of the induction of abortion. A thirty-four-year-old
patient, gravida five, second month, inserted a piece of wood into the
cervix. After a week of intermittent bleeding, an abortion occurred.
Fever had been present, but now became septic in type. Death oc¬
curred eighteen days after induction.

“The Analysis Committee considered the following case typical of
a non-preventable death in septic abortion. A thirty-three-year-old
woman, having had ten pregnancies and with seven living children,
aborted spontaneously at the second month. After bleeding for two
weeks she called a physician who prescribed rest and medication. Even
with help of her unemployed husband, the nursing care of her small
children prevented her from following directions. A phlebitis de¬
veloped, accompanied by chills, sweats and vomiting. The patient
finally entered the hospital on the twenty-fourth day and died six
hours after admission77 (p. 48).

Sharp criticism of the methods of handling abortion by physicians is
also voiced in the Children's Bureau report. They say (p. 114) :

“The most frequent operation in the management of these abortions
was curettage (usually with sharp instruments, which is a procedure
definitely to be condemned). It is clear that many physicians did not
consider fever a contra-indication for curettage ; yet in those cases in
which it was known that fever existed and curettage was done, 94
per cent of the deaths were due to sepsis. In marked contrast is the
fact that only 50 per cent of the deaths of the women who were
afebrile at time of operation were due to sepsis. In not a few cases
the history of an induced abortion was not discovered until after the
patient had been curetted or even after she had died. Evidently a
careful history in many of these cases was not obtained .

“As pernicious vomiting was the principal indication for 112 of
the therapeutic abortions, it would seem that the physicians had de¬
layed in doing the abortion or had been called in consultation too late
to save the patient's life, or else had improper technique.

“This study shows very clearly the seriousness of the problem
created by the great number of abortions that are induced each year.
II also shows that the practice of curetting every patient who has an
abortion is common. Physicians must be made to appreciate the
seriousness of curetting these potentially septic cases. The manage-

386

ABORTION

ment of an abortion calls for the best medical care that can be given,
and in many of the cases in this series it is obvious that such care
was not given.’7

Additional Data on Abortion Mortality

Liepmann claims that the maternal deaths from abortion have been
underestimated rather than overestimated. Figures such as those of
Schottelius for Hamburg, with 183 deaths out of 8,107 abortions or
2.3 per cent, and Benthin of 1.9 per cent, are considered insufficient.
Schaefer from Berlin cites 6,270 abortions with 3.25 per cent mortal¬
ity. Bleichroder found a death rate of 3.36 per cent in 2,617 abor¬
tions. Kiefer reported 152 deaths out of 3,800 abortions, 4 per cent.
Dietrich’s figures were even as high as 4.5 per cent mortality. Com-
michau in Jena finds an increasing mortality of abortions from 0.39
per cent (1910-1914) to 3.58 per cent (1915-1918) and 5.4 per cent
(1919-1926).

Discrepancies. — There is an apparent contradiction between figures
pointing on the one hand to a decline in the mortality rate following
abortion, and on the other hand pointing to an increase in abortion
deaths. This can readily be explained. In the years before the war
non-criminal abortions were treated by physicians very largely out¬
side of hospital conditions, very often without due care for asepsis.
The criminal abortions, on the other hand, were in great part done
by midwives or by the patients themselves. This led naturally to a
high percentage of infection, hemorrhage and perforation, with a re¬
sulting high mortality. Since the war, in most countries, there has
unquestionably been a marked increase in the number of abortions,
associated undoubtedly with an increase in the total number of deaths
following abortion.

A careful analysis of statistics of various countries, however, con¬
vinces one that the actual mortality from abortion has in the larger
cities shown a definite decrease (see Fig. 142). This can readily be
explained in the case of the spontaneous abortion by better medical care,
especially a fuller appreciation of the risks of infection, and better
facilities for hospitalization resulting in a larger number of these cases
obtaining hospital care. In the case of the criminal or illegal abor¬
tion, women have come more and more to abstain from personal at¬
tempts, or the employment of the midwife. The professional abor¬
tionist, usually a physician, has paid greater attention to asepsis in
his manipulations and simpler methods of procedure, with the result
that relatively fewer deaths have occurred. An additional factor in
the lowering of the death rate, although not a lowering in the total
number of deaths, is that in the past ten years these criminal proce-

STATISTICS OF ABORTION

387

dures have been done more frequently in married women having sev¬
eral children, than in the unmarried, and as a rule have been done
within the first two months, owing in part to earlier diagnosis of
pregnancy by the Aschheim-Zondek test.

SUMMARY

From this review of the statistical evidence on abortion we cull a
few of the more striking facts :

POST WAIT ABORTION DEATH -RATES

DeaiKs per IOOO Abortions
iqi Cj- lcjzq

-Reported bij Peller from. Bu.din.per
34 Fh e

Fig-. 142. — Fall in abortion deaths in Germany during- decade following War.
(From Biidinger, as reported by Peller in Fehlgeturt und Bevolkerungsfrage, Stutt¬
gart, 1930.)

( 1 ) An approximation of the truth concerning abortion can be ar¬
rived at by collecting evidence independently on three points : the
total number of abortions, the abortion death rate, and the total
abortion deaths. This must show that the total number of abortions
times the death rate equals the abortion deaths.

For the United States the figures obtained showed that 681,600 abor¬
tions times a death rate of 1.2 per cent equalled about 8,000 abortion
deaths annually.

388

ABORTION

(2) In the past forty years there has been a marked increase in the
number of abortions, due to a widespread resort to induced interrup¬
tion. The years immediately following the war and the recent period
of depression have shown the most pronounced increase in the number
of abortions.

( 3 ) With the decrease in birth rates during this period, the ratio of
abortions to confinements has changed from 1 to 7 forty years ago,
to 1 to 3 at the present time. In some industrial centers the number
of abortions approximately equals the number of full-term deliveries.

(4) Of the total abortions only 25 to 30 per cent are spontaneous,
10 to 15 per cent are therapeutic and about 60 to 65 per cent are
illegally induced.

(5) Over one-half of the illegal inductions of abortion are done by
physicians, one-fifth by midwives and the remainder by the patients
themselves.

(6) The vast majority of all abortions equalling 90 per cent occur
among married pregnant women, especially those between 25 and 35
years of age who have had several children. The recent increase in
abortions has been primarily in this group. Among unmarried preg¬
nant women the greater proportion of abortions occur in the younger
age groups.

(7) Abortions, both spontaneous and induced, occur most frequently
in the second and third months of gestation.

(8) The religious affiliation of the patient has relatively little in¬
fluence on the incidence of abortion.

( 9 ) The rate of abortion deaths is half again as high among the
negro as among the white women in this country, but the total ma¬
ternal death rate among negroes is twice that of the whites.

(10) The number of abortions and the number of abortion deaths
is proportionately twice as great in the cities as in country districts.

(11) Abortion constitutes the greatest single factor in our high
puerperal mortality, one-fourth of the total amount. Of the deaths
from puerperal septicemia alone, abortion is responsible for practi¬
cally one-half.

(12) Analysis of the causes of death following abortion shows that
in about three cases in four the deaths were preventable.

(13) Evidence points to some diminution in recent years in the
death rate from abortion owing to improved technique by the abor¬
tionist and a widening of indications for legalized abortion in many
countries. This is more than counter-balanced by the increase in the
total number of abortions, so that the abortion deaths still show an

increase.

CHAPTER XXIV

ECONOMIC AND DOMESTIC ASPECTS OF INDUCED

ABORTION

0 POWERFUL and universal is the instinct tor motherhood that,

^ when a woman is impelled to do away with the child within her
body, we may feel sure the fault lies primarily with the special con¬
ditions under which she is living. Here and there selfish reasons may
enter into the problem, but certainly in the vast majority of cases
external factors are largely responsible. The medical reasons which
make interruption of pregnancy necessary, as already discussed, are
usually beyond our direct control. Indirectly, however, some control
can be effected even here by the prevention of conception in these
women, since only a small portion of the medical conditions indicating
abortion arise during pregnancy. Pregnancy should, as a rule, never
have been allowed to occur, and for this situation we physicians must
ourselves largely take the blame.

The underlying faults in our social structure that have led to the
present alarming number of abortions can be grouped under five
heads :

(1) Economic distress

(2) Occupational changes

(3) Illegitimacy

(4) Domestic relations

(5) Fear of confinement.

(1) Economic distress is at the root of the largest number of in¬
duced abortions. In Russia, where each woman must give the reason
for the interruption of pregnancy, a tabulation of the records of
hundreds of thousands showed that poverty and bad living con¬
ditions were emphasized in over one-half of the cases. While other
countries have no similar tabulation of reasons for desiring abortion,
there is general agreement that a direct relationship exists between
induced abortion and destitution. In Dr. Kopp’s analysis of 11,172
abortions in New York City, there was evidence of an increasing num¬
ber of inductions with the increase in family; when the number of
children was over three, women could less frequently afford to pay
a physician for their abortion and had to resort to a midwife, or more
often were compelled to terminate the pregnancy by self-instrumen¬
tation.

389

390

ABORTION

The distressing conditions under which some women have to face
a new pregnancy have been revealed by numerous investigations on
maternal welfare here and abroach Sydenstricker ys survey, reported
at the Washington Conference on Birth Control in 1934, showed that
the highest birth-rates occurred among unemployed workers ; that is
to say, those in the worst economic status, and these findings have
been reinforced by later studies.

Liepmann, in Germany, calls attention to the living conditions of
280,000 women with five or more children. One thousand five hundred
and seven, families lived in one room ; 29,880 lived in two rooms including
the kitchen; 89,089 lived in three rooms including the kitchen;
and 82,079 lived in four rooms including the kitchen. Living con¬
ditions were found to be bad for 45 per cent of the families with
pregnant mothers. Liepmann argues that it is unjust to compel these
women to give birth to children under such circumstances. Associated
with these cramped home surroundings there are usually insufficient
heat and ventilation, while improper and insufficient food, want of
clothing and inadequate sanitation complete the picture. Can we
wonder that when women are faced with a new pregnancy they grasp
at any means of interruption? Even the payment of a fee to a doctor
or midwife is less costly than having another mouth to feed and an¬
other body to clothe and care for. Under social conditions such
as these the surprising thing is not that there are so many abortions,
but that there are not more of them. Only the long discipline of
patient suffering has enabled women to carry on under these handicaps.

(2 ; Occupational chang’es in the past fifty years have also materially
influenced the incidence of induced abortion. With the spread of the
Woman's Suffrage Movement throughout the world and the newer
economic independence of women, the revolt of womankind against
the age-long domination of man has finally materialized. There can
be no question that more consideration must be given to the right of
women to control their own bodies. It will take generations, however,
before any radical changes occur, for the vast majority of women
everywhere are still subservient to men.

Unusual ability in artistic, intellectual and administrative fields
has ena

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